Appendix B. CY 2025 Part D EOB Exhibit E

Model Part D EOB EXHIBIT E

EXHIBIT E. Example of Chart 4 (Changes to the Formulary)
The pages that follow show an example of Chart 4 in the model Part D EOB. Chart 4 gives updates to the
formulary.
This example is for a fictional MA-PD plan called “Birchwood Medicare Plus.” The Part D sponsor has met all
requirements and has the option to immediately replace brand name drugs with their generic equivalents. The
example illustrates model language for six different types of changes. It uses placeholders for the names of the
drugs. To help show how this section would look in an actual Part D EOB, the example includes fictional
information for the rest of the drug-related text. To help members scan quickly through the list, the drug names
are accented with boxes.

Model Part D EOB EXHIBIT E
CHART 4

Changes to our Drug List that affect drugs you take
We may make changes to our Drug List during the year, like adding new drugs, removing drugs, changing
coverage restrictions, or moving drugs from one cost-sharing tier to another. The information below shows
updates that affect plan-covered prescriptions you filled in 2025.

[Drug A]
Step therapy
• Starting June 1, 2025, “step therapy” will be required for this drug. This means you’ll be required to try a
different drug first before we’ll cover [Drug-name A]. This requirement encourages you to try another drug
that costs less but is just as safe and effective as [Drug-name A]. If this other drug doesn’t work for you,
the plan will then cover [Drug-name A].

Understanding these changes

How much will you pay?

• See the next page for places to get help and more
information about your options.
• You and your doctor may want to consider trying
[alternate drug 1] or [alternate drug 2]. Both are on
our Drug List and have no coverage restrictions.
They’re used in similar ways as [Drug A] and
they’re on a lower cost-sharing tier.

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-555-1212
(TTY 1-888-555-1313).

[Drug B]
Quantity limit
• Starting October 1, 2025, there’ll be a new limit on the amount of the drug you can have: no more than
60 tablets (extended release 80 mg tablets) for a 30 day supply will be covered.

Understanding these changes

How much will you pay?

See the next page for places to get help and more
information about your options.

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-555-1212
(TTY 1-888-555-1313).

Model Part D EOB EXHIBIT E

[Drug C]
Prior authorization
• Starting June 1, 2025, “prior authorization” will be required for this drug. This means you or your doctor
need to get approval from the plan before we’ll cover it.

Understanding these changes

How much will you pay?

• See the next page for places to get help and more
information about your options.
• Your choices include asking for prior authorization
in order to continue having this drug be covered
for you, or changing to a different drug.

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-555-1212
(TTY 1-888-555-1313).

[Drug D]
Generic replacement
• Starting June 1, 2025, the brand-name drug [Brand Drug D] was removed from our Drug List. We added
a new generic version of [Brand Drug D] to the Drug List called [Generic Drug D].

Understanding these changes

How much will you pay?

• We replaced [Brand Drug D] because [Generic
Drug D], a new generic version of [Brand Drug D],
is available. This change can save you money
because [Generic Drug D] (tier 1) is in a lower
cost-sharing tier than [Brand Drug D] (tier 3).
• If your prescriber believes this generic drug isn’t
right for you due to your medical condition, you or
your prescriber can ask us to make an exception.
• See the next page for places to get help and more
information about your options.

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-555-1212
(TTY 1-888-555-1313).

Model Part D EOB EXHIBIT E

[Drug E]
Cost-sharing increase
• Starting July 1, 2025, the brand-name drug [Brand Drug E] will move from tier 2 to a higher cost-sharing
tier (tier 3).

Understanding these changes

How much will you pay?

• See the next page for places to get help and more
information about your options.
• You and your doctor may want to consider trying a
lower cost generic drug, [Alternate Generic Drug
1], which is in cost-sharing tier 1.

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-555-1212
(TTY 1-888-555-1313).

[Drug F]
Removed from Drug List
• Starting October 1, 2025, the brand-name drug [Brand Drug F] will be removed from our Drug List. If
you’re taking this drug now, this change won’t affect your coverage for this drug for the rest of the plan
year.
• We’ll add [Brand Drug G] to our Drug List, which is less costly yet just as safe and effective as [Brand
Drug F].

Understanding these changes

How much will you pay?

See the next page for places to get help and more
information about your options.

The amount you’ll pay depends on which drug
payment stage you’re in when you fill the
prescription. To find out how much you’ll pay, call
Birchwood Member Services at 1-800-555-1212
(TTY 1-888-555-1313).