CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Presc

2022 Part D EOB Exhibit B

Exhibit B. Examples that show different versions of Section 1 (the list of prescriptions)

NOTE: The examples in this exhibit have been designed to illustrate some of the main variations in model language for Section 1 of the model Part D Explanation of Benefits (EOB). This section shows the list of prescriptions filled by a plan member.

These examples of Section 1 use numbers for the year 2022 and placeholders for the names of drugs. To help show how Section 1 would look in an actual Part D EOB, the examples include fictional information for the rest of the prescription-related text.

PART 1 2

Example s 1-2: variations in text at end of Chart 1 that explain the totals 2

[Example 1: Deductible payme nt stage, no payme nts from plan or others] 3

[Example 2: Initial cove rage stage, payme nts from plan, from Extra Help, and from anothe r organization] 5

PART 2 9

[Example 3: Using a separate chart for Supple me ntal Drug Cove rage ] 10

PART 3 11

Example 4: Using “notes” on Chart 1 to show changes to the formulary 11

[Example 4: Excerpt from Chart 1 showing notes about changes to the formulary] 12

PART 1.

Examples 1-2: variations in text at end of Chart 1 that explain the totals

Examples 1 and 2 are designed to illustrate differences in the wording of the text that explains the total amounts which appear at the bottom of the Chart 1 list of prescriptions. These examples are for plan members who have no supplemental drug coverage. Each is in a different payment stage:

• Example 1 shows a version of Section 1 for a plan member who is in the deductible payment stage. This member receives no payments from the plan or from third parties.

• Example 2 shows a version of Section 1 for a plan member who is in the initial coverage period. This member receives payments from the plan, from the Extra Help program (these payments count toward out-of-pocket costs), and from Worker’s Compensation (these payments do not count toward out-of-pocket costs).

[Example 1: Deductible payment stage, no payments from plan or others]

SECTION 1. Your prescriptions during the past month

• Chart 1 shows your prescriptions for covered Part D drugs for the past month.

• Please look over this information about your pre scriptions and che ck to see that it’s corre ct. If you have any questions or there’s a mistake, Section 5 shows you what to do.

• Drug Pricing Information (Drug Price & Price Change)

  • The Drug Price shows the cost of each drug (including what you, your plan and other programs paid). The Price Change

shows the percentage of the drug price since it was first filled during this benefit year.

• There may be Lower Cost The rape utic Alternative drugs (when applicable) listed below some of your current drugs. These are drugs that may be an alternative to the ones you are taking but with lower cost-sharing or a lower drug price. You may want to speak with your prescriber to see if the lower cost therapeutic alternative is right for you.

CHART 1. Your prescriptions for covered Part D drugs March 2022	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)	Drug Price & Price Change
{inse rt name of first drug} 40 mg tabs
03/09/22, ABC Pharmacy Rx# 106663421555, 30 day supply	$0.00	$45.18	$0.00	$45.18 +4%
Lower Cost Therapeutic Alternative(s):
{inse rt name of second drug} 25 mg caps
03/09/22, ABC Pharmacy Rx# 349000711222, 30 day supply	$1.20	$13.80	$0.00	$15.00 -3.5%
Lower Cost Therapeutic Alternative(s):

(continued)

TOTALS for the month of March 2022: Your “out-of-pocke t costs” amount is $58.98. (This is the amount you paid this month ($58.98) plus the amount of “other payments” made this month that count toward your “out-of-pocket costs” ($0.00). See definitions in Section 3.) Your “total drug costs” amount is $58.98. (This is the total for this month of all payments made for your drugs by the plan ($0.00) and you ($58.98) plus “other payments” ($0.00).)

$0.00 (total for the month)

$58.98 (total for the month)

$0.00 (total for the month)

Year-to-date totals 1/1/22 through 3/31/22	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)
Your ye ar-to-date amount for “out-of-pocke t costs” is $58.98. Your ye ar-to-date amount for “total drug costs” is $58.98. For more about “out-of-pocket costs” and “total drug costs,” see Section 3.	$0.00 (year-to-date total)	$58.98 (year-to-date total)	$0.00 (year-to-date total)

[Example 2: Initial coverage stage, payments from plan, from Extra Help, and from another organization]

SECTION 1. Your prescriptions during the past month

• Chart 1 shows your prescriptions for covered Part D drugs for the past month.

• Please look over this information about your pre scriptions and che ck to see that it’s corre ct. If you have any questions or think there’s a mistake, Section 5 shows you what to do.

• Drug Pricing Information (Drug Price & Price Change)

  • The Drug Price shows the cost of each drug (including what you, your plan and other programs paid). The Price Change

shows the percentage of the drug price since it was first filled during this benefit year.

• There may be Lower Cost The rape utic Alternative drugs (when applicable) listed below some of your current drugs. These are drugs that may be an alternative to the ones you are taking but with lower cost-sharing or a lower drug price. You may want to speak with your prescriber to see if the lower cost therapeutic alternative is right for you.

CHART 1. Your prescriptions for covered Part D drugs March 2022	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)	Drug Price & Price Change
{inse rt name of first drug} inj 100 u/ml 03/09/22, ABC Pharmacy Rx# 124868934511, 15 day supply Lower Cost Therapeutic Alternative(s):	$107.11	$21.42	$14.28 (paid by “Extra Help”)	$142.81 +3.0%

CHART 1. Your prescriptions for covered Part D drugs March 2022	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)	Drug Price & Price Change
{inse rt name of second drug} 240 mg caps 03/12/22, ABC Pharmacy Rx# 316582122880, 30 day supply Lower Cost Therapeutic Alternative(s):	$6.60	$1.32	$2.26 (paid by “Extra Help”)	$10.18 -1.1%
{inse rt name of third drug} 150 mg tabs 03/15/22, ABC Pharmacy Rx# 632005552144, 30 day supply Lower Cost Therapeutic Alternative(s):	$326.90	$10.00	$43.59 (paid by “Extra Help”) $65.38 (paid by Worker’s Compensation)	$445.87 -8.4%
{inse rt name of fourth drug} 50 mg tabs 03/15/22, ABC Pharmacy Rx# 529042917765, 30 day supply Lower Cost Therapeutic Alternative(s): NOTE: Beginning on June 1, 2022, step therapy will be required for this drug. See Section 4 for details.	$60.17	$12.03	$8.02 (paid by “Extra Help”)	$80.22 +1.1%

CHART 1. Your prescriptions for covered Part D drugs March 2022	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)	Drug Price & Price Change
{inse rt name of first drug} 100 u/ml 03/15/22, ABC Pharmacy Rx# 124868900912, 15 day supply Lower Cost Therapeutic Alternative(s):	$107.11	$21.42	$14.28 (paid by “Extra Help”)	$142.81 +11.2%

TOTALS for the month of March 2022: Your “out-of-pocke t costs” amount is $148.62. (This is the amount you paid this month ($66.19) plus the amount of “other payments” made this month that count toward your “out-of-pocket costs” ($82.43). See definitions in Section 3.) Your “total drug costs” amount is $821.89. (This is the total for this month of all payments made for your drugs by the plan ($607.89) and you ($66.19) plus “other payments” ($147.81).)

$607.89 (total for the month)

$66.19 (total for the month)

$147.81 (total for the month) (Of this amount, $82.43 counts toward your “out- of-pocket costs.” See definitions in Section 3.)

Not applicable

(continued)

Year-to-date totals as of 3/31/2022	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)
Your ye ar-to-date amount for “out-of-pocke t costs” is $690.80. Your ye ar-to-date amount for “total drug costs” is $2,136.26. For more about “out-of-pocket costs” and “total drug costs,” see Section 3.	$1,314.70 (year-to-date total)	$445.20 (year-to-date total)	$376.36 (year-to-date total) (Of this amount, $245.60 counts toward your “out- of-pocket costs.” See definitions in Section 3.)

PART 2.

[Example 3: Using a separate chart for Supplemental Drug Coverage]

Example 3 that follows shows a version of Chart 2, which is used to show prescriptions that are covered under the plan’s Supplemental Drug Coverage. This chart follows Chart 1 (it comes immediately after the summary of year-to-date totals).

Showing a separate chart for prescriptions covered under the plan’s Supplemental Drug Coverage helps reduce potential confusion by emphasizing that payments for these prescriptions do not count toward members’ out-of-pocket costs or total drug costs.

NOTE: When Chart 2 is included in an EOB, the following sentence is added to the first bulleted point in the introductory section of Chart 1: “(Prescriptions for drugs covered by our plan’s Supplemental Drug Coverage are shown separately in Chart 2).”

[Example 3: A separate chart (Chart 2) for prescriptions covered by Supplemental Drug Coverage]

CHART 2.

Your prescriptions for drugs covered by our plan’s Supplemental Drug Coverage

March 2022

This chart shows your prescriptions for drugs that are not generally covered by Medicare. These drugs are covered for you under our plan’s Supplemental Drug Coverage.	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)
{insert name of drug} 0.5 mg 03/01/22, ABC Pharmacy Rx# 836725300111, 30 day supply	$2.80	$5.00	$0.00
Totals for the month of March 2022 $2.80 $5.00 $0.00 These payments do not count toward your “out-of-pocket costs” or your “total drug costs” because they are for drugs that are not generally covered by Medicare. (See definitions in Section 3.)

PART 3.

Example 4: Using “notes” on Chart 1 to show changes to the formulary

Example 4 shows how explanatory notes are used in Section 1. These notes can provide members additional information related to a prescription, such as notes that highlight general price increases for that drug, or when a payment for a drug does not count toward out-of-pocket costs, or the drug is only partially covered because it is a compound drug that includes non- Part D drugs. The plan may also suggest lower-cost alternatives that a member and his/her doctor might consider in this section.

[Example 4: Excerpt from Chart 1 showing notes about changes to the formulary]

SECTION 1. Your prescriptions during the past month

• Chart 1 shows your prescriptions for covered Part D drugs for the past month.

• Please look over this information about your pre scriptions and che ck to see that it’s corre ct. If you have any questions or think there’s a mistake, Section 5 shows you what to do.

• Drug Pricing Information (Drug Price & Price Change)

  • The Drug Price shows the cost of each drug (including what you, your plan and other programs paid). The Price Change

shows the percentage of the drug price since it was first filled during this benefit year.

• There may be Lower Cost The rape utic Alternative drugs (when applicable) listed below some of your current drugs. These are drugs that may be an alternative to the ones you are taking but with lower cost-sharing or a lower drug price. You may want to speak with your prescriber to see if the lower cost therapeutic alternative is right for you.

CHART 1. Your prescriptions for covered Part D drugs March 2022	Plan paid	You paid	Other payments (made by programs or organizations; see Section 3)	Drug Price & Price Change
{insert name of first drug} 30 mg tabs
03/11/22, ABC Pharmacy Rx# 222003740005, 30 day supply Lower Cost Therapeutic Alternative(s):	$48.29	$16.21	$0.00	$64.50 +1.3%
NOTE: Beginning on June 1, 2022, step therapy will
be required for this drug. See Section 4 for details.
{insert name of second drug} 50 mg caps 03/21/22, ABC Pharmacy	$72.34	$22.60	$0.00	$94.94

Rx# 671142913332, 30 day supply Lower Cost Therapeutic Alternative(s): NOTE: Beginning on June 1, 2022, step therapy will be required for this drug. See Section 4 for details.				-7.4%
{inse rt name of third drug} 0.5 mg 03/25/22, ABC Pharmacy Rx# 444025344660, 30 day supply Lower Cost Therapeutic Alternative(s): NOTE: Effective June 1, 2022, this drug will be moved from cost-sharing tier 2 to a higher cost- sharing tier (tier 3). See Section 4 for details.	$2.80	$5.00	$0.00	$7.80 -2.1%

{NOTE: This example shows only the first part of Chart 1. The rest of the chart is not included.}