Appendix B. CY 2025 Part D EOB Exhibit C

Model Part D EOB EXHIBIT C

EXHIBIT C. Examples that show different versions of Chart 3: drug payment
stages
The examples in this exhibit are for a fictional enrollee and have been designed to illustrate some of the main
variations in model language for Chart 3 of the Model Part D Explanation of Benefits (EOB). These examples
use 2024 benefit parameters 1 where 2025 benefit parameters are not yet available. For ease of illustration, the
amounts for Out-of-Pocket Costs and Total Drug Costs have been rounded.

Example 1: non-LIS, with a deductible, in the Deductible Stage ............................................................... 2
Example 2: non-LIS, with a deductible, in the Initial Coverage Stage ........................................................ 3
Example 3: non-LIS, with a deductible, in the Catastrophic Coverage Stage .............................................. 4
Example 4: non-LIS, no deductible, in the Initial Coverage Stage ............................................................. 5
Example 5: non-LIS, brand-name/tier level only deductible, in the Initial Coverage Stage ........................... 6
Example 6: LIS in the Initial Coverage Stage.......................................................................................... 7
Example 7: LIS in the Catastrophic Coverage Stage ................................................................................ 8

See the April 4, 2023 Health Plan Management System (HPMS) memorandum titled “Final Contract Year (CY) 2024 Part D Bidding
Instructions.

1

1

Model Part D EOB EXHIBIT C

Example 1: non-LIS, with a deductible, in the Deductible Stage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill
it. This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to
the next stage.

Year-to-date totals:
Jan – March 2025
Out-of-Pocket Costs

You’re in
Stage 1:
Yearly
Deductible
$255

Stage 2:
Initial
Coverage

Stage 3:
Catastrophic
Coverage

starts when
Out-of-Pocket
Costs reach
$545

starts when
Out-of-Pocket
Costs reach
$2,000

You’re in Stage 1: Yearly Deductible
• During this payment stage, you (or others on your
behalf) pay the full cost of your drugs.
• You generally stay in this stage until you (or
others on your behalf) have paid $545 for your
drugs.
• The deductible doesn’t apply to covered insulin
products and most adult Part D vaccines,
including shingles, tetanus and travel vaccines..

What happens next?
Once you (or others on your behalf) have paid an
additional $290 for your drugs, you move to the
next payment stage (Stage 2: Initial Coverage).

About Coverage Stages

• Stage 1: Yearly Deductible
You start in this payment stage each calendar year. In this stage, you pay the full cost of your drugs. You
generally stay in this stage until you’ve paid the amount of your deductible ($545).
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the
rest of the calendar year.

2

Model Part D EOB EXHIBIT C

Example 2: non-LIS, with a deductible, in the Initial Coverage Stage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill
it. This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to
the next stage.

Year-to-date totals:
Jan – March 2025

Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

lasts until
Out-of-Pocket
Costs
reach $545

You’re in
Stage 2:
Initial
Coverage

$836

Stage 3:
Catastrophic
Coverage

starts when
Out-of-Pocket
Costs
reach $2,000

You’re in Stage 2: Initial Coverage
• During this payment stage, the plan pays its share
of the cost of your drugs and you (or others on
your behalf) pay your share of the cost.
• You generally stay in this stage until your year-todate Out-of-Pocket Costs reach $2,000.00. As of
March 31, 2025, your year-to-date Out-of-Pocket
Costs were $836.

What happens next?
Once you have an additional $1,164 in Out-ofPocket Costs, you move to the next payment
stage (Stage 3: Catastrophic Coverage).

About Coverage Stages

• Stage 1: Yearly Deductible
You start in this payment stage each calendar year. In this stage, you pay the full cost of your drugs. You
generally stay in this stage until you’ve paid the amount of your deductible ($545).
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.00.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the
rest of the calendar year.

3

Model Part D EOB EXHIBIT C

Example 3: non-LIS, with a deductible, in the Catastrophic Coverage Stage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it.
This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to the
next stage.

Year-to-date totals:
Jan – March 2025
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

Stage 2:
Initial
Coverage

lasts until
Out-of-Pocket
Costs
reach $545

lasts until Outof-Pocket
Costs reach
$2,000

You’re in Stage 3: Catastrophic Coverage
• During this payment stage, you pay nothing for
your covered Part D drugs.

You’re in
Stage 3:
Catastrophic
Coverage
$2,000

What happens next?
You generally stay in this stage for the rest of the
calendar year.

About Coverage Stages

• Stage 1: Yearly Deductible
You start in this payment stage each calendar year. In this stage, you pay the full cost of your drugs. You
generally stay in this stage until you’ve paid the amount of your deductible ($545).
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the
rest of the calendar year.

4

Model Part D EOB EXHIBIT C

Example 4: non-LIS, no deductible in the Initial Coverage Stage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it.
This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to the
next stage.

Year-to-date totals:
Jan – March 2025
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

not applicable

You’re in
Stage 2:
Initial
Coverage

$703

Stage 3:
Catastrophic
Coverage
starts when
Out-of-Pocket
costs
reach $2,000

You’re in Stage 2: Initial Coverage

• During this payment stage, the plan pays its
share of the cost of your drugs and you (or others
on your behalf) pay your share of the cost.
• You generally stay in this stage until your yearto-date Out-of-Pocket Costs reach $2,000. As
of March 31, 2025, your year-to-date Out-ofPocket Costs were $703.

What happens next?
Once you have an additional $1,297 in Out-ofPocket Costs, you move to the next payment
stage (Stage 3: Catastrophic Coverage).

About Coverage Stages

• Stage 1: Yearly Deductible
Because there is no deductible for the plan, this payment stage does not apply to you.
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the
rest of the calendar year.

5

Model Part D EOB EXHIBIT C

Example 5: non-LIS, brand-name/tier level only deductible, in the Initial
Coverage Stage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it.
This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to the
next stage.

Year-to-date totals:
Jan – March 2025

Out-of-Pocket Costs

Stage 1:
Yearly
Deductible
lasts until
Out-of-Pocket
Costs reach $545
for brand-name
(tier 3) drugs

You’re in
Stage 2:
Initial
Coverage

$836

Stage 3:
Catastrophic
Coverage
starts when
Out-of-Pocket
Costs
reach $2,000

You’re in Stage 2: Initial Coverage

• During this payment stage, the plan pays its share
of the cost of your drugs and you (or others on
your behalf) pay your share of the cost.
• You generally stay in this stage until your year-todate Out-of-Pocket Costs reach $2,000. As of
March 31, 2025, your year-to-date Out-of-Pocket
Costs were $836.

What happens next?
Once you have an additional $1,164 in Out-ofPocket Costs, you move to the next payment
stage (Stage 3: Catastrophic Coverage).

About Coverage Stages

• Stage 1: Yearly Deductible
You start in this payment stage each calendar year. In this stage, you pay the full cost of your drugs. You
generally stay in this stage until you’ve paid the amount of your deductible ($545 for your brandname, or tier 3, drugs.)
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the rest
of the calendar year.

6

Model Part D EOB EXHIBIT C

Example 6: LIS in the Initial Coverage Stage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it.
This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to the
next stage.

Year-to-date totals:
Jan – March 2025
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

not applicable

You’re in Stage 2: Initial Coverage
• You start in this payment stage when you fill your
first prescription of the year.
• During this stage, the plan pays its share of the
cost of your drugs and you (or others on your
behalf, including “Extra Help” from Medicare) pay
your share of the cost.
• You generally stay in this stage until your yearto-date Out-of-Pocket Costs reach $2,000. As
of March 31, 2025, your year-to-date Out-ofPocket Costs were $625.

About Coverage Stages

You’re in
Stage 2:
Initial
Coverage

$625

Stage 3:
Catastrophic
Coverage
starts when
Out-of-Pocket
Costs
reach $2,000

What happens next?
Once you have an additional $1,375 in Out-ofPocket Costs, you move to the next payment
stage (Stage 3: Catastrophic Coverage).

• Stage 1: Yearly Deductible
Because you get “Extra Help” from Medicare, Stage 1: Yearly Deductible doesn’t apply to you.
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the
rest of the calendar year.

Model Part D EOB EXHIBIT C

Example 7: LIS in Catastrophic Coverage
CHART 3

Your current drug payment stage
How much you pay for a covered Part D prescription depends on which payment stage you’re in when you fill it.
This chart helps you understand what stage you were in at the end of March 2025 and when you’ll move to the
next stage.

Year-to-date totals:
Jan – March 2025
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

Stage 2:
Initial
Coverage

not applicable

lasts until Outof-Pocket
Costs reach
$2,000

You’re in Stage 3: Catastrophic Coverage
• During this payment stage, you pay nothing for
your covered Part D drugs.

About Coverage Stages

You’re in
Stage 3:
Catastrophic
Coverage
$2,000

What happens next?
You generally stay in this stage for the rest of the
calendar year.

• Stage 1: Yearly Deductible
Because you get “Extra Help” from Medicare, Stage 1: Yearly Deductible doesn’t apply to you.
• Stage 2: Initial Coverage
In this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.
You generally stay in this stage until your year-to-date Out-of-Pocket Costs reach $2,000.
• Stage 3: Catastrophic Coverage
In this stage, you pay nothing for your covered Part D drugs. You generally stay in this stage for the
rest of the calendar year.