CMS-10453 Part D EOB Plan Instructions

General Instructions for Plans
•

•

This is a Part D model EOB. Your EOB must include all model language exactly as written, except:
o Minor grammar or punctuation changes and font type or color changes.
o References to a specific plan name in brackets may be replaced with generic language such as “our
plan.”
o References to Member Services may be changed to the name your plan uses.
o References to the plan’s Supplemental Drug Coverage may be changed to the name your plan uses.
(This is coverage for non-Part D drugs.)
o References to “cost-sharing tiers” may be expanded to include additional description, including the
standardized names of the tiers used by your plan.
o References to “brand-name/tier-level” deductible may be changed to the appropriate name your
plan uses.
o Date formatting (such as “mm/dd/yy”), unless specific date formatting instructions are given.
o References to “calendar year” may be changed to “plan year”.
Italicized blue text in square brackets is information for the plans, and shouldn’t be included in the EOB.

•

Non-italicized blue text in square brackets may be inserted or used as replacement text in the EOB. Use it
as applicable.

•

The plan type designation (i.e., HMO, PPO, etc.) must be included the first time the plan name is
mentioned (see model language for the cover).

•

Medicare-Medicaid Plans: If you choose the Part D Model EOB, we require the EOB to contain all
information and follow all of our model instructions. We expect Medicaid-covered drugs will be included
in the model.

Formatting guidelines
•

So standard window envelopes can be used, the model language in the Appendix, Exhibit A, includes a
version of the cover page in portrait orientation and a version in landscape orientation. Plans may use
either orientation for all pages of the document. Instructions to plans are shown in this document on the
portrait version of the cover. These same instructions apply if the landscape version is used.

•

The document can be printed double-sided to save space.

•

Plans are permitted to eliminate empty spaces between sections and/or widen text boxes and columns to
save space.

•

The document must include page numbers.

•

Plans must include the following information as a footer on every page excluding the cover page (where
the information is already included): the plan name, plan phone number, including the TTY number and a
statement that calls to the plan are free, and plan URL. Plans may choose to add a header or footer that
includes some or all of this information: member identifiers; month and year; additional contact
information; page number.
Charts that continue from one page to the next must be marked with “continue” at the bottom on the page
that continues. In an actual EOB, rows of a chart must not break across the page (in the model language in
this document, rows sometimes break across a page because of the instructions and substitution text).

•

•

Costs included may be displayed with or without decimals and cents (e.g. $0.00).

•

For examples that show versions of the cover page and each section of the EOB, see Exhibits A through F.
Exhibit G shows an example of a complete EOB. This exhibit helps you visualize what the document will
look like when substitution text is used in various situations.

Drug Pricing Information (Drug Price & Price Change):
•

The Drug Price column shows the negotiated price as defined at 423.100.

•

The Price Change shows the percentage change of the drug price from when the prescription was first
filled during the current benefit year.

•

Plans have the flexibility to determine how many lower-cost therapeutic alternative drugs they list;
however, plans must provide at least 1 drug for each filled prescription if there is a lower-cost
therapeutically equivalent drug available. Plans should use their clinical expertise when deciding which
alternative drugs to list. If no lower-cost therapeutically equivalent drug is available, plans may enter “No
lower-cost alternative drug is available.”

•

Prior year fills that don’t apply to the current EOB or current year gross covered prescription drug costs
or true out-of-pocket (TrOOP) amounts don’t need to be included in this EOB, and don’t require a
separate EOB.

Important things to know
•

“Extra Help” refers to the low-income subsidy (LIS) described in Subpart P of the Part D regulations.

•

“Out-of-Pocket Costs” and “TrOOP” refer to the enrollee’s incurred costs, as defined at 1860D2(b)(4)(C).

•

“Total Drug Costs” refers to gross covered prescription drug costs, as defined at 1860D-15(b)(3).

•

Do not provide information in the Part D EOB about drugs or supplies that would be covered for a
beneficiary in original Medicare under Parts A and/or B; for an enrollee in a Part C plan under the
plan’s Part A/B coverage.

•

In charts 1, 1A, and 2, the amounts to be used for “you paid” are the final amounts after “other
payments” (those made by programs, organizations, or other plans; “other payments” may include
TrOOP and non-TrOOP amounts).

•

Plans may use the optional notes that give members more information about a prescription (such as notes
for when a payment for a drug doesn’t count toward Out-of-Pocket Costs, or the drug is only partially
covered because it’s a compound drug that includes non-Part D drugs).

•

If the Total Drug Costs and Out-of-Pocket Costs change due to an automatic TrOOP balance transfer for
the current year, the plan must send the EOB showing the changes in the year-to-date totals in Chart 2
and Chart 3. If a plan transfer happens in a given month, the EOB must be sent even if there were no
prescriptions filled in the month before. The note regarding the transferred amounts must stay in Chart 2
for the rest of the year.

•

When a beneficiary disenrolls from a plan during the plan year, the sponsor must send an EOB to the
beneficiary after disenrollment if any claims are processed before the beneficiary disenrolls. For example,
if beneficiaries disenroll at the end of August and the plan processes claims in months before they
disenroll, the disenrolling plan must send the beneficiaries a final EOB.

Page 1 of [number of pages]

[Insert plan name and/or logo.]
[Insert plan name followed by model
type shown in parentheses, e.g.,
“(HMO)”] is operated by [insert plan
sponsor name]
[insert return mailing address].

THIS IS NOT A BILL

[Insert beneficiary name.]
[Insert beneficiary mailing address.]

Notice for [Insert beneficiary name]
Your Medicare Number

[Insert Medicare
number]

Date of This Notice

[Insert mailing date]

Claims for

[Insert name of
month and full year]

Your Medicare Part D Explanation of Benefits (EOB)
This is your “Explanation of Benefits” (EOB) for your Medicare prescription drug coverage (Part D). Your EOB shows
the prescriptions you filled, what we paid, what you and others have paid, and what counts towards your Out-ofPocket Costs and your Total Drug Costs.
•

Your EOB is not a bill.
If you paid a co-pay or coinsurance for your drug, the EOB should show the amount you paid. If you
participate in the Medicare Prescription Payment Plan, we’ll send you a separate monthly billing statement,
and amounts shown in this EOB might differ from what you paid. Contact us if you have questions or want
more information. Visit Medicare.gov for information about the Medicare Prescription Payment Plan.

•

You may not get an EOB every month.
When we get a claim (bill) from your pharmacy, you’ll get an EOB the next month. For example, if we get a
claim in March, you’ll get an EOB in April.

•

Take a minute to look over your EOB.
Check your EOB to make sure everything is correct. If you have questions, find mistakes, or suspect fraud,
we’re happy to help. Call us at the number below.

[Insert plan name and/or logo]
Member Services
If you have questions or need help, call us
toll-free [insert days of week and calling hours].
[insert phone number]
[add local number if desired]
TTY users call [insert TTY number]
Or visit our website:
[insert URL]

For languages other than English:
[Appropriate language as described in the Medicare
Communications and Marketing Guidelines, including
disclaimers, should be in this document.]
Need large print or another format?
To get this material in other formats, including large type,
braille, and translation into other languages, call [insert
plan name] at the number on this page.

THIS IS NOT A BILL | Page 2 of [number of pages]

[In chart 1, the amounts to be used for “you paid” are the final amounts after “other payments” (those made by programs,
organizations, or other plans; “other payments” may include TrOOP and non-TrOOP amounts).]
CHART 1

Your MONTHLY prescriptions for covered Part D drugs: [MONTH YEAR]

[If member has filled prescriptions for non-Part D drugs covered by the plan’s supplemental drug coverage
during the past month, include Chart 1A in the EOB and add the following sentence here: (Prescriptions for drugs
covered by our plan’s Supplemental Drug Coverage are shown separately in Chart 1A.)]

Totals for the month of [Month Year]

• Your Out-of-Pocket Costs amount is $[insert total
paid by member for the month plus total of “other
payments” that count toward the member’s
TrOOP limit; use “$0.00” if applicable]
• Your Total Drug Costs amount is $[insert Total
Drug Costs for the month; use “$0.00” if
applicable]

Drug Name, Fill Date,
Pharmacy, Rx#
[insert name of first drug], 40 mg
tabs
04/09/25, ABC Pharmacy
Rx# 106663421555, 30 day supply

You
Paid

Plan
Paid

$X

$X

[insert name of second drug], 10
mg tabs
04/09/25, ABC Pharmacy
Rx# 349000711222, 30 day supply

$X

$X

Totals for the month of
[Month Year]

$X

$X

•

•
•
•

Other
Payments
$X
[insert
“paid by”
name of
payer]
$X
[insert
“paid by”
name of
payer]

Drug
Price

$X

$X

$X

$X

Lower Cost
Price
Change Alternative Drugs
[insert name of
lower cost
[percent
alternative drug]
change]
[insert name of
lower cost
[percent
alternative drug]
change]

[If the EOB is being sent to a member who hasn’t filled any prescriptions for covered Part D drugs during the
month, plans must (1) insert the following note in first column: “No prescriptions for covered Part D drugs this
month,” (2) insert amounts of “$0.00” for the columns labeled “Plan paid,” “You paid” and “Other payments….”
and (3) omit the row with “Totals for the month…” at the end of this chart.]
You Paid Column: [insert total paid by member for the month. Use “$0.00” if applicable]
Plan Paid Column: [Insert total amount paid by the plan this month; use $0.00 if applicable.]
Other Payments Column: [Insert total amount of “other payments” for the month; use $0.00 if applicable.] [If
amount is not $0.00, and there are any payments that don’t count toward TrOOP, add this text: (Of this amount,
$[insert amount that does count toward TrOOP] counts toward your Out-of-Pocket Costs.]

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 3 of [number of pages]

You Paid

This is the amount you paid for each drug. It
includes any payments for your drugs made by
family or friends. If you participate in the Medicare
Prescription Payment Plan, we’ll send you a
separate monthly billing statement, and the
amounts here might differ from what you paid.

Plan Paid

This is the amount [insert plan name] paid for each
drug.

Other Payments

This shows any payments not included in the “You
Paid” and “Plan Paid” columns, such as those
made by Extra Help from Medicare, employer or
union health plans, TRICARE, Indian Health
Service, AIDS drug assistance programs,
Manufacturer Discount Program, charities, and
State Pharmaceutical Assistance Programs
(SPAPs). Some of these payments may not count
towards your Out-of-Pocket Costs.

Drug Price

This shows the cost of each drug (including
payments made by you, your plan, and others).

Price Change

This shows how the drug price changed (as a
percentage) from when your prescription was first
filled during the benefit year. You’ll only see a
drug price change when the quantity dispensed
was the same.

Lower Cost Alternative Drugs

This shows drugs that may be an alternative to the
ones you’re taking now, but with lower cost sharing
or a lower drug price. You may want to ask your
doctor if the lower cost alternative is right for you.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 4 of [number of pages]

[In chart 1A, the amounts to be used for “you paid” are the final amounts after “other payments” (those made by
programs, organizations, or other plans).]
CHART 1A

Your prescriptions for drugs covered by your plan’s Supplemental Drug
Coverage: [MONTH YEAR]
[Include Chart 1A only if the EOB is for a plan member who has filled at least one prescription during the month for a
non-Part D drug that is covered by the plan’s Supplemental Drug Coverage.

Don’t give information in the Part D EOB about drugs or supplies that would be covered for a beneficiary in original
Medicare under Parts A and/or B; for an enrollee in a Part C plan under the plan’s Part A/B coverage; or otherwise
covered under non-Medicare insurance.]
Your Supplemental Drug Coverage pays for some drugs not generally covered by Medicare. Any prescriptions
you filled for these drugs this month are listed in the chart below. The amounts paid for these drugs do not
count toward your Out-of-Pocket Costs or Total Drug Costs.
Drug Name, Fill Date,
Pharmacy, Rx#
[Insert name of drug (other than
compound) followed by quantity,
strength, and form, e.g., “25 mg
tabs”. Identify compound drugs
as such and provide quantity.]

You
Paid

[Insert date filled]. [Plans should
include the pharmacy name if
known. Plans may add the
pharmacy location, and other
pharmacy information if desired,
such as “non-network pharmacy.”]
[Insert prescription number], [Insert
amount dispensed, as quantity filled
and/or days supply, e.g., “15
tablets”, “30 day supply.”] [Plans
may add more information about the
prescription if desired]

[Insert amount. Use
$0.00 if applicable.]

Plan
Paid

Other
Payments

[Insert amount. Use
$0.00 if applicable. For
each payment, identify
[Insert amount. Use
the payer if known. If
$0.00 if applicable.]
payer isn’t known,
identify as “other
payer.”]

[Plans are encouraged to use the
optional notes to give members
more information about a
prescription, such as notes about
general price increases for that
drug, or when a payment for a drug
doesn’t count toward Out-of-Pocket
Costs, or the drug is only partially
covered because it’s a compound
drug that includes non-Part D
If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 5 of [number of pages]

drugs. In this section, the plan may
also suggest lower-cost alternatives
members and their doctors might
consider.]
Totals for the month of
[Month Year]
[Insert totals for the month under
each column. Use $0.00 if
applicable]

$

$

$

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 6 of [number of pages]

[In chart 2, the amounts to be used for “you paid” are the final amounts after “other payments” (those made by programs,
organizations, or other plans; “other payments” may include TrOOP and non-TrOOP amounts).]
CHART 2

Your YEARLY spending totals for covered Part D drugs
Your year-to-date Out-of-Pocket Costs amount is
$[insert year-to-date TrOOP; use “$0.00” if
applicable] (includes what You Paid plus Other
Payments)

Monthly totals:
[Month Year]

You
Paid

Plan
Paid

Other
Payments
$X

Total
Drug Costs

$X

$X

[insert “paid by”
name of payer]

$X

Year-to-date totals:
$X
$X
$X
$X
Jan – [Month Year]
• You Paid Column: [Insert how much the member has paid year-to-date; use $0.00 if applicable.] (Year-to-date total).
[If total isn’t $0.00 and any of this total doesn’t count toward Out-of-Pocket Costs, insert: (Of this amount, $[insert
amount paid that does count toward Out-of-Pocket Costs] counts toward your Out-of-Pocket Costs.)]
• Plan Paid Column: [Insert how much the plan’s paid year-to-date; use $0.00 if applicable.] (Year-to-date total)
• Other Payments Column: [Insert year-to-date total for “other payments”; use $0.00 if applicable] (Year-to-date total).
[If total isn’t $0.00 and there are any payments that don’t count toward Out-of-Pocket Costs, insert: (Of this amount,
$[insert amount that does count toward Out-of-Pocket Costs] counts toward your “Out-of- Pocket Costs.” See
definitions in Section 3.)]
• [If the member was enrolled in a different plan for Part D coverage earlier in the year, plans must insert the following:
“NOTE: Your year-to-date totals shown here include Out-of-Pocket Costs payments of $[insert the TrOOP balance
transferred from prior plan] and $[insert amount for Total Drug Costs] in Total Drug Costs made for your Part D
covered drugs when you were in a different plan earlier this year.”]
• [Optional: If corrections have been made that affect amounts shown in monthly summaries earlier in the calendar year,
plans may explain in this space: “NOTE: The following [insert whichever applies: correction has OR corrections have
OR adjustment has OR adjustments have] been made to amounts that were in a monthly summary sent to you earlier
this calendar year: [Plans should give a brief explanation of the correction or adjustment with the change that was
made and gives relevant dates and a reason for the change, e.g., clerical error, updated information about the
prescription, decision on an appeal, etc.“ Plans have the flexibility to report such adjustments or corrections to
members in other ways instead of, or in addition to, adding this explanatory note to the EOB.]
• [Optional: Plans can add as a bullet under “Out-of-Pocket Costs include”: “Supplemental drug benefits paid by your
plan.”]

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 7 of [number of pages]

You Paid

This is the amount you paid for each drug. It
includes any payments for your drugs made by
family or friends. If you participate in the Medicare
Prescription Payment Plan, we’ll send you a
separate monthly billing statement, and amounts
here might differ from what you paid.

Plan Paid

This is the amount [insert plan name] paid for each
drug.

Total Drug Costs

This is the total of all payments made for your
covered Part D drugs. It includes:

• What the plan pays
• What you pay
• What other programs or organizations pay for
your drugs

Other Payments
This shows any payments not included in the “You
Paid” and “Plan Paid” columns, such as those made
by Extra Help from Medicare, employer or union
health plans, TRICARE, Indian Health Service,
AIDS drug assistance programs, Manufacturer
Discount Program, charities, and State
Pharmaceutical Assistance Programs (SPAPs).
Some of these payments may not count towards
your Out-of-Pocket Costs.

Out-of-Pocket Costs include:
• What you paid when you fill/refill a covered Part
D prescription
• Any payments for your drugs made by family or
friends
• Any payments made for your drugs by Extra
Help from Medicare, employer or union health
plans, TRICARE, Indian Health Service, AIDS
drug assistance programs, charities, and most
State Pharmaceutical Assistance Programs
(SPAPs)

Out-of-Pocket Costs DON’T include
payments made for:

• Plan premiums
• Drugs not covered by our plan
• Non-Part D drugs (like drugs you get during a
hospital stay)
• Drugs covered by certain other programs, such
as the Veteran’s Administration or Worker’s
Compensation
• Manufacturer Discount Program
• Selected drug subsidy
• [insert if applicable: Drugs covered by our plan’s
Supplemental Drug Coverage listed in Chart 1A]
• [insert if applicable: Drugs you got from a nonnetwork pharmacy that doesn’t meet our
requirements]

Learn more
Medicare made the rules about which types of
payments count toward “Out-of-Pocket Costs” and
“Total Drug Costs.” For more details, see [insert
plan name]’s Evidence of Coverage benefits booklet.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 8 of [number of pages]

[NOTE TO PLANS ABOUT CHART 3:
To standardize the EOB, this section on drug payment stages always shows all 3 stages. When a drug payment stage
doesn’t apply to members, the model language includes an explanation to say so.
Language in Chart 3 is customized for the payment stage the member is in. Each stage’s wording varies, including
variations for plan design (e.g., deductible vs. brand-name/tier level only deductible vs. non-deductible) and for LIS
(non-LIS vs. LIS). This section can be suppressed when the enrollee is a full benefit dual eligible and is either
institutionalized or receiving home and community-based waiver services (LICS level 3).
To make the substitution text easier to follow, this model document gives you different versions of Chart 3 for each
payment stage, with separate versions for LIS and non-LIS. The non-LIS versions are shown first, followed by those for
LIS.
For a quick overview of how the language and formatting accents change from one stage to the next, for non-LIS and
LIS, see the examples in Exhibit C in the Appendix.]

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 9 of [number of pages]

[Use this version of CHART 3 for members without LIS who are 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 [insert month and year] and when you’ll
move to the next stage.

Year-to-date totals:
Jan – [insert name of
month and full year]

Out-of-Pocket Costs

You’re in
Stage 1:
Yearly
Deductible

Stage 2:
Initial
Coverage

Stage 3:
Catastrophic
Coverage

$X

starts when
Out-of-Pocket Costs
reach $[insert annual
deductible amount]

starts when
Out-of-Pocket Costs
reach $[insert TrOOP
limit]

You’re in Stage 1: Yearly Deductible
•
•

•

•
•

During this payment stage, you (or others on
your behalf) pay the full cost of your drugs.
The deductible doesn’t apply to covered insulin
products and most adult Part D vaccines,
including shingles, preventative tetanus and
travel vaccines.
You generally stay in this stage until you (or
others on your behalf) have paid $[insert
annual deductible amount] for your drugs. [If
the plan has a brand-name/tier level deductible,
insert the following three bullets.]
During this payment stage, you (or others on
your behalf) pay the full cost of your [brandname/tier level] drugs.
You generally pay the full cost of your [brandname/tier level] drugs until you (or others on
your behalf) have paid $[insert deductible

•

amount] for your [brand-name/tier level] drugs.
$[insert deductible amount] is the amount of
your [brand-name/tier level] deductible.
As of [insert end date for the month] you’ve
paid $[insert year-to-date Deductible Drug
Costs] for your drugs in the deductible.

What happens next?
Once you (or others on your behalf) have paid
an additional $[insert additional amount
needed to satisfy the deductible] 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 ($[insert annual
deductible]).

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 10 of [number of pages]

•

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 $[insert TrOOP
limit].

•

Stage 3: Catastrophic Coverage
In this stage, the plan pays all of the cost for your covered Part D drugs. You pay nothing. You generally
stay in this stage for the rest of the calendar year.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 11 of [number of pages]

[Use this version of CHART 3 for members without LIS who are 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 [insert month and year] and when you’ll
move to the next stage.

Year-to-date totals:
Jan – [insert name of
month and full year]
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible
lasts until
Out-of-Pocket Costs
reach $[insert annual
deductible]

You’re in Stage 2: Initial Coverage
•

•
•

During this payment stage, the plan pays its
share of the cost of your [insert if applicable:
generic/ tier levels] 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 $[insert
TrOOP limit].
As of [insert end date of month], your year-todate Out-of-Pocket Costs were $[insert year-todate out-of-pocket costs].

You’re in
Stage 2:
Initial
Coverage
$X

Stage 3:
Catastrophic
Coverage
starts when
Out-of-Pocket Costs
reach $[insert TrOOP
limit]

What happens next?
Once you have an additional $[insert
amount needed in additional TrOOP to
meet the TrOOP limit] in Out-of-Pocket
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 ($[insert annual
deductible]).

•

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 $[insert TrOOP
limit].

•

Stage 3: Catastrophic Coverage
In this stage, the plan pays all of the cost for your covered Part D drugs. You pay nothing. You generally
stay in this stage for the rest of the calendar year.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 12 of [number of pages]

[Use this version of CHART 3 for members without LIS who are 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 [insert month and year] and when you’ll
move to the next stage.

Year-to-date totals:
Jan – [insert name of
month and full year]
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

lasts until Out-oflasts until
Pocket
Costs reach
Out-of-Pocket Costs reach
$[insert
TrOOP limit]
$[insert annual
deductible]

You’re in Stage 3: Catastrophic Coverage
•
•

Stage 2:
Initial
Coverage

During this payment stage, the plan pays all of
the cost for your covered Part D drugs.
You pay nothing.

You’re in
Stage 3:
Catastrophic
Coverage
$X

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 ($[insert annual
deductible]).

•

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 $[insert TrOOP
limit].

•

Stage 3: Catastrophic Coverage
In this stage, the plan pays all of the cost for your covered Part D drugs. You pay nothing. You generally
stay in this stage for the rest of the calendar year.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 13 of [number of pages]

[Use this version of CHART 3 for members with LIS who are 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 [insert month and year] and when you’ll
move to the next stage.

Year-to-date totals:
Jan – [insert name of
month and full year]
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 payment stage, the plan pays its
share of the cost of your [insert if applicable:
generic/ tier levels] 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 $[insert
year-to-date TrOOP]. As of [insert end date of
month], your year-to-date Out-of-Pocket Costs
were $[insert year-to-date TrOOP].
•

You’re in
Stage 2:
Initial
Coverage

Stage 3:
Catastrophic
Coverage

$X

starts when
Out-of-Pocket Costs
reach $[insert TrOOP
limit]

What happens next?
Once you have an additional $[insert amount
needed in additional TrOOP to meet the
TrOOP limit] in Out-of-Pocket Costs, you
move to the next payment stage (Stage 3:
Catastrophic Coverage).

About Coverage Stages
•

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 $[insert TrOOP
limit].

•

Stage 3: Catastrophic Coverage
In this stage, the plan pays all of the cost for your covered Part D drugs. You pay nothing. You generally
stay in this stage for the rest of the calendar year.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 14 of [number of pages]

[Use this version of CHART 3 for members with LIS who are 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 [insert month and year] and when you’ll
move to the next stage.

Year-to-date totals:
Jan – [insert name of
month and full year]
Out-of-Pocket Costs

Stage 1:
Yearly
Deductible

Stage 2:
Initial
Coverage

You’re in
Stage 3:
Catastrophic
Coverage

not applicable

lasts until Out-ofPocket Costs reach
$[insert TrOOP limit]

$X

You’re in Stage 3: Catastrophic Coverage
•
•

During this payment stage, the plan pays all of
the cost for your covered Part D drugs.
You pay nothing.

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

About Coverage Stages
•

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 $[insert TrOOP
limit].

•

Stage 3: Catastrophic Coverage
In this stage, the plan pays all of the cost for your covered Part D drugs. You pay nothing. You generally
stay in this stage for the rest of the calendar year.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 15 of [number of pages]

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 provides
updates that affect plan-covered prescriptions you filled in [insert coverage year].
• [Use this section to give formulary updates that affect drugs the member is taking, i.e., any plan-covered drugs the
member filled a prescription for during the current calendar year while a member of the plan. Include updates only
if they affect drugs the member is taking. (Changes to the formulary from one year to the next are announced in the
ANOC and do not need to be included in the EOB.) This would include covered Part D drugs and supplemental
drugs listed in Charts 1 and 1A of Section 1, but not those that would be covered for a beneficiary in original
Medicare under Parts A and/or B; for an enrollee in a Part C plan under the plan’s Part A/B coverage; or
otherwise covered under non-Medicare insurance.]
• [If there are no updates, replace all of the text that follows this section with: “At this time, there are no new or
upcoming changes to our Drug List that will affect the coverage or cost of drugs you take. (By “drugs you take,” we
mean any plan-covered prescriptions you filled in [insert year] as a member of our plan.)”]
• If an update is for a negative formulary change that isn’t a formulary maintenance change, insert: “If you’re taking
this drug now, this change won’t affect your coverage for this drug for the rest of the plan year.”]]
• [Below we show model language for reporting several common types of changes to the Drug List for you to use as
applicable. Plans may adapt this language as needed for grammatical consistency, accuracy, and relevant detail
(e.g., describing a drug as “brand-name” or “generic”). Plans may also explain changes and suggest specific drugs
that might be suitable alternatives. For changes we haven’t given you model language for, use the model language
below as a guide. Also, see the examples in Exhibit E in the Appendix.]
[Insert name of step therapy drug; plans may also insert information about the drug’s strength or
the form it’s dispensed in (e.g., tablets, injectable, etc.)]
Step therapy
• Starting [insert effective date of change], “step therapy” will be required for this drug. This means you
will be required to try [insert either: a different drug first OR one or more other drugs first] before we’ll
cover [name of step therapy drug]. This requirement encourages you to try another drug that costs less
but is just as safe and effective as [insert name of step therapy drug]. If [insert either: this other drug
doesn’t OR the other drugs don’t] work for you, the plan will then cover [insert name of step therapy
drug].

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
[insert plan name] at [insert member services phone
number] (TTY [insert TTY number]).

• [If applicable, plans may insert information
that shows possible alternate drug(s). For
example, “(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 [name of
step therapy drug] and they’re on a lower
cost-sharing tier.)”]

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 16 of [number of pages]

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
[insert plan name] at [insert member services phone
number] (TTY [insert TTY number]).

• [If applicable, plans may insert information
that shows possible alternate drug(s). For
example, “(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 [name of
step therapy drug] and they’re on a lower
cost-sharing tier.)”]

[Insert name of drug with quantity limits; plans may also insert information about the drug’s strength
or the form it’s dispensed in (e.g., tablets, injectable, etc.)]
Quantity limit
• Starting [insert effective date of change], there’ll be a new limit on how much of the drug you can have:
[insert description of how the quantity will be limited].

Understanding these changes

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

How much will you pay?

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
[insert plan name] at [insert member services
phone number] (TTY [insert TTY number]).

[Insert name of prior authorization drug; plans may also insert information about the drug’s strength
or the form it’s dispensed in (e.g., tablets, injectable, etc.)]
Prior authorization
• Starting [insert effective date of change], “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
See the next page for places to get help and more
information about your options.
[Plans may insert more explanation, for
example, “Your choices include asking for prior
authorization to continue having this drug
covered or changing to a different drug.]

How much will you pay?
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
[insert plan name] at [insert member services
phone number] (TTY [insert TTY number]).

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 17 of [number of pages]

[You can use the language below with appropriate modifications and within required timeframes to notify
enrollees about immediate generic substitutions by Part D sponsors meeting the requirements, as well as
other generic changes.
[Insert name of brand-name drug that has been or will be replaced with generic or whose preferred or
tiered cost-sharing or restrictions or both changed (or will change) with the addition of the new
generic drug; plans may also insert information about the strength or form in which the drug is
dispensed (e.g., tablets, injectable, etc.)]
Generic replacement
•

Starting [insert effective date of the change], the brand-name drug [insert name of brand-name drug to
be replaced with generic] [insert either: “will be” OR “was”] [state if brand-name drug is being substituted
or if there is a change to the brand-name drug’s cost-sharing tier or restrictions with the addition of the
generic drug or both. For instance,] removed from our Drug List. We [insert either: “will add” OR “added”]
a new generic version of [insert name of brand-name drug to be replaced with generic] to the Drug List
(it is called [insert name of replacement generic drug]).

• We’re [insert either: “replacing” OR “replaced” [name of brand-name drug] OR [insert as applicable:
“changed” OR “are changing” “cost-sharing” OR "restrictions” OR “cost-sharing and restrictions” for
[insert brand-name drug] because [insert name of generic drug], a [insert if applicable “new”] generic
version of [insert name of brand-name drug to be replaced with generic], is available now. [Indicate tier
placement of generic drug. For instance, “[Insert name of generic drug] (tier [insert cost-sharing tier
number or name for the replacement generic drug]) is on [insert either: “the same” OR a “lower” costsharing tier than [name of brand-name drug], the drug it [insert either: “is replacing” OR “replaced”]
[insert if generic drug is on a lower cost-sharing tier: (tier [insert cost-sharing tier number or name for the
brand-name drug that is being replaced.])

Understanding these changes

How much will you pay?

If your doctor thinks this generic drug isn’t right for
you, you can ask us to make an exception.
See the next page for places to get help and more
information about your options.
[Plans may insert further information if applicable.
For example, “This change can save you money
because [insert name of replacement generic drug]
(tier [insert cost-sharing tier number or name for
the replacement generic drug]) is in a lower costsharing tier than [insert name of brand-name drug
to be replaced with generic] (tier [insert costsharing tier number or name for the replacement
generic 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
[insert plan name] at [insert member services
phone number] (TTY [insert TTY number]).

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 18 of [number of pages]

[Insert name of drug for which cost-sharing will increase; plans may also insert information about the
strength or form in which the drug is dispensed (e.g., tablets, injectable, etc.)]
Cost-sharing increase
• Starting [insert effective date of the change], [insert description of the change, for example, “the brandname drug [insert name of drug for which cost-sharing will increase] will move from tier 2 to a higher costsharing 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.
[Plans may add more information, for example,
“(You and your doctor may want to consider trying
a lower cost generic drug, [insert name of lowercost generic drug], which is in cost-sharing tier
[insert number or name of 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
[insert plan name] at [insert member services
phone number] (TTY [insert TTY number]).

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].

THIS IS NOT A BILL | Page 19 of [number of pages]

Important things to know about your drug coverage and your rights
See mistakes or have questions?
If you have questions, see mistakes, or suspect
fraud, call [insert plan name] Member Services at
[insert Member Services phone number] (TTY
[insert TTY number]). You can also find answers to
many questions online at [insert URL]. Or, call
Medicare at 1-800-MEDICARE (1-800-633-4227).
TTY users can call 1-877-486-2048.
You can also call your State Health Insurance
Assistance Program (SHIP). The name and phone
numbers for your state SHIP are in Chapter 2,
Section 3 of your Evidence of Coverage.

Get help with your options

Here are some things you can do to help you and your
doctor manage any changes in coverage:
Call [insert plan name] Member Services to ask for
a list of covered drugs that treat the same medical
condition. This list can help your doctor to find a
covered drug that might work for you and have fewer
restrictions or a lower cost.
You and your doctor can ask us to make an
exception for you. This means asking us to agree
that the change in coverage or cost-sharing tier of a
drug doesn’t apply to you. To learn how to ask for an
exception, see [MA-PD insert: Chapter 9] [PDP
insert: Chapter 7] in the Evidence of Coverage, “What
to do if you have a problem or complaint.”

Get help paying for your drug coverage

“Extra Help” from Medicare. If you meet certain
income and resource limits, you may qualify for Extra
Help. This program helps pay for your Medicare drug
coverage costs, such as plan premiums, deductibles,
and costs when you fill your prescriptions. To see if
you qualify for Extra Help, complete an application
online at https://secure.ssa.gov/i1020/start. You can
also call Social Security toll-free at 1-800-772-1213
(TTY 1-800-325-0778).
Help from your State Pharmaceutical Assistance
Program. Many states have State Pharmaceutical
Assistance Programs (SPAPs) that help people pay for
prescription drugs based on financial need, age, or
medical condition. Each state has different rules. To
find out if your state has a State Pharmaceutical
Assistance Program, visit Medicare.gov and search for
“SPAP.” Or, check with your local State Health
Insurance Assistance Program (SHIP).

Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan can help you
manage your drug costs by spreading them out during
the year as monthly payments. This program is
available to anyone with Medicare Part D and can be
especially helpful to people with high cost sharing
earlier in the plan year. Contact us or visit Medicare.gov
to learn more about this program.

Get help with drug coverage or payment
problems

Your Evidence of Coverage explains what to do if you
have problems related to your drug coverage and costs.
Here are the chapters to look for:
[MA-PD insert: Chapter 7.] [PDP insert: Chapter 5.]:
Asking the plan to pay its share of a bill you have
received for covered services or drugs
[MA-PD insert: Chapter 9.] [PDP insert: Chapter 7.]:
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Get more details in the Evidence of
Coverage [if EOB is for a member with
LIS, insert “and LIS Rider”]

The Evidence of Coverage is our plan’s benefits
booklet. It explains your drug coverage and the rules
you need to follow to use your coverage. To get a copy
of the Evidence of Coverage in your mail or email, call
[insert plan name] Member Services at [insert Member
Services phone number] (TTY [insert TTY number]).
You can also get this document online at [insert URL]. [If
EOB is for a member with LIS, insert: Your LIS Rider
(“Evidence of Coverage Rider for People Who Get Extra
Help Paying for their Prescriptions”) is a short separate
document that tells what you pay for your prescriptions.]

Your right to appeal

When we decide whether a drug is covered and how
much you must pay, it’s called a “coverage decision.” If
you disagree with our coverage decision, you can
appeal (see [MA-PD insert: Chapter 9] [PDP insert:
Chapter 7] of the Evidence of Coverage).
Medicare sets the rules for how coverage decisions and
appeals are handled. These are legal procedures and
the deadlines are important. The process can be
expedited if your doctor tells us that your health requires
a quick decision.

If you have questions, please call [insert plan name] at [insert Member Services phone number] (TTY [insert
TTY number]). The call is free. For more information, visit [insert URL].