CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stage
Medicare Prescription Drug Benefit Program - IRASA (CMS-10141)
Attachment 3d. CY 2022 EOB Exhibit C
Medicare Prescription Drug Benefit Program (Plans)
OMB: 0938-0964
2022
Part
D
EOB
Exhibit
C
EXHIBIT C. Examples that show different versions of Section 2 (drug payment stages)
NOTE: The examples in this exhibit are fictional. They have been designed to illustrate some of the main variations in model language for Section 2 of the model Part D Explanation of Benefits (EOB). These examples use numbers for the year 2022. For ease of illustration, the amounts for out-of-pocket costs and total drug costs have been rounded.
PART 1. Examples 1-4: non-LIS, with a de ductible and limited gap coverage 3
[Example 3: non-LIS, with a deductible and limite d gap cove rage, in the Cove rage Gap] 8
[Example 4: non-LIS, with a deductible and limite d gap cove rage, in Catastrophic Cove rage ] 10
PART 2. Example 5: non-LIS, no de ductible and no gap coverage 12
PART 3. Example 6: non-LIS, brand-name /tier level only de ductible and no gap coverage 15
PART 4. Examples 7-9: partial LIS, with a de ductible 18
[Example 7: partial LIS, with a de ductible , in the Ye arly de ductible stage] 19
[Example 8: partial LIS, with a deductible, in the Initial Cove rage Stage ] 21
[Example 9: partial LIS, with a deductible, in Catastrophic Cove rage ] 22
PART 5. Example 10: full LIS, in a plan that has a de ductible 23
[Example 10: full LIS, in a plan with a de ductible , in the Initial Coverage Stage ] 24
PART 1. Examples 1-4: non-LIS, with a deductible and limited gap coverage
(these examples begin on the next page)
[Example 1: non-LIS, with a deductible and limited gap coverage, in the yearly deductible stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
During this
payment stage,
you (or others on your behalf) receive a 70%
manufacturer’s
discount on
covered brand name drugs and the plan will
cover
[insert
if additional brand gap coverage:
“at
least”] another
5%,
so
you
will
pay [insert
if additional brand gap coverage: “less
than”] 25%
of
the negotiated
price on brand-name drugs.
In addition
you (or others
on your behalf) pay [insert
if additional
generic
gap
coverage: “less
than”] 25%
of the costs of generic drugs.
You generally
stay in
this stage until
the amount of your
year-to-date
“out-of-
STAGE
4 Catastrophic
Coverage
During
this
payment stage,
the plan pays
most of the cost
for your covered
drugs.
You generally stay in
this stage
for the
rest of the
calendar year (through
December 31, 2022).
What happens next?
Once you (or others on your behalf) have paid an additional
$280 for your drugs, you move to the next payment stage (stage 2, Initial Coverage).
pocket costs” (see Section 3) reaches $ 7,050. When this happens, you move to payment stage 4, Catastrophic Coverage.
[Example 2: non-LIS, with a deductible and limited gap coverage, in the Initial Coverage Stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
During this
payment stage,
you (or others on your behalf) receive a 70%
manufacturer’s
discount on
covered brand name drugs and the plan will
cover [insert
if additional brand gap coverage: “at
least”] another
5%,
so
you
will
pay [insert
if additional brand gap coverage: “less
than”] 25%
of
the negotiated
price on brand-name drugs.
In addition
you (or others
on your behalf) pay [insert
if additional
generic
gap
coverage: “less
than”] 25%
of the costs of generic drugs.
You generally stay
in this stage
until the amount
of your
year-to-date
“out-of-
STAGE
4 Catastrophic
Coverage
During
this
payment stage,
the plan pays
most of the cost
for your covered
drugs.
You generally stay in
this stage
for the
rest of the
calendar year (through
December 31, 2022).
[Example 3: non-LIS, with a deductible and limited gap coverage, in the Coverage Gap]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
4 Catastrophic
Coverage
During this payment
stage, the plan pays
most of
the cost
for your covered
drugs.
You generally stay in
this stage
for the
rest of the
calendar year (through
December 31, 2022).
|
What happens next? |
Once you (or others on your behalf) have paid an additional $3,850 in “out-of-pocke t costs,” you move to the next payment stage (stage 4, Catastrophic Coverage). |
[Example 4: non-LIS, with a deductible and limited gap coverage, in Catastrophic Coverage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
During this
payment stage,
you (or others on your behalf) receive a 70% manufacturer’s
discount
on
covered brand name drugs and the plan will cover [insert
if
additional brand gap coverage: “at
least”] another 5%, you will
pay [insert
if
additional
brand gap coverage:
“less
than”]
25%
of
the negotiated
price
on brand-name
drugs.
In
addition you
(or others
on
your
behalf) pay
[insert if
additional
generic
gap coverage: “less
than”]
25%
of
the costs of
generic drugs.
You generally stay in
this stage until the amount of
your
“out-of-pocket
costs”
reaches $7,050. When you move to payment stage 4, Catastrophic Coverage.
PART 2. Example 5: non-LIS, no deductible and no gap coverage
(this example is on the next page)
[Example 5: non-LIS, no deductible and no additional gap coverage, in the Initial Coverage Stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
During
this
payment
stage,
you (or others
on your behalf)
receive a 70% manufacturer’s
discount on
covered brand
name drugs and the plan will
cover
another 5%,
so you
will pay
25% of the
negotiated price
on brand- name
drugs. In
addition you (or
others on your behalf) pay
25% of the costs of generic drugs.
You generally stay in
this stage until the
amount of your
year-to- date “out-of-pocket
costs” (see Section
3) reaches
$7,050. Then you
move to payment stage 4, Catastrophic
Coverage.
STAGE
4 Catastrophic
Coverage
During this payment
stage, the plan pays
most of
the cost
for your covered
drugs.
You generally stay in
this stage
for the
rest of the
calendar year (through
December 31, 2022).
PART 3. Example 6: non-LIS, brand-name/tier level only deductible and no gap coverage
(this example is on the next page)
[Example 6: non-LIS, brand-name/tier level only deductible and no gap coverage, in the Initial Coverage Stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
During this payment
stage, you (or others on
your behalf) receive a 70% manufacturer’s discount
on covered brand name drugs and the plan will
cover another 5%, so
you will pay 25%
of the negotiated price on brand-name drugs.
In addition you
(or others on your
behalf) pay
25% of the costs of generic drugs.
You generally stay in
this stage until the
amount of your
year-to- date “out-of-pocket costs” (see Section
3) reaches $7,050. Then
you move to payment
STAGE
4
Catastrophic
Coverage
During
this
payment stage,
the plan pays
most of the cost
for your covered
drugs.
When you
are in
this stage, you
generally stay in
it for the
rest of the
calendar year (through December 31, 2022).
PART 4. Examples 7-9: partial LIS, with a deductible
(these examples begin on the next page)
[Example 7: partial LIS, with a deductible, in the Yearly deductible stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
(Because you
are
receiving “Extra
Help” from Medicare, this payment
stage does
not apply to you.)
STAGE
4 Catastrophic
Coverage
During this payment
stage, the
plan pays
most of the cost for your covered drugs.
You generally
stay in
this stage for the rest of the calendar
year (through December 31,
2022).
[Example 8: partial LIS, with a deductible, in the Initial Coverage Stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
(Because you
are receiving “Extra
Help” from
Medicare, this payment
stage does not apply to you.)
STAGE
4 Catastrophic
Coverage
During
this
payment stage,
the plan pays
most of the cost
for your covered
drugs.
You generally stay in
this stage
for the
rest of the
calendar year (through
December 31, 2022).
[Example 9: partial LIS, with a deductible, in Catastrophic Coverage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
STAGE
3 Coverage
Gap
(Because you
are
receiving “Extra
Help” from Medicare, this payment
stage does
not apply to you.)
PART 5. Example 10: full LIS, in a plan that has a deductible
The page that follows has an example that illustrates what the drug payment stages chart in Section 2 looks like for someone with full LIS who is in drug payment stage 2 (Initial Coverage). The purpose of this example is to show how the model language explains the absence of a deductible for someone with full LIS who is in a plan that has a deductible.
(this example is on the next page)
[Example 10: full LIS, in a plan with a deductible, in the Initial Coverage Stage]
SECTION 2. Which “drug payment stage” are you in?
As shown below, your Part D prescription drug coverage has “drug payment stages.” How much you pay for a covered Part D prescription depends on which payment stage you are in when you fill it. During the calendar year, whether you move from one payment stage to the next depends on how much is spent for your drugs.
You
are
in
this
stage:
STAGE
2 Initial
Coverage
You
begin
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
the amount of your ye
ar-to-date
“out-of- pocket costs” reaches $7,050. As
of 08/31/22
your
year-to-date
“out-of-pocket
costs”
were $4,130
(see
definitions
in Section
3).
What
happens
next?
Once
you (or
others
on
your behalf)
have paid
an
additional
$2,920
in
out-of-
pocket
costs
for
your
drugs,
you
move
to
STAGE
3 Coverage
Gap
(Because you
are
receiving
“Extra
Help” from
Medicare, this payment stage does not apply
to you.)
STAGE
4 Catastrophic
Coverage
During this payment
stage, the
plan pays
for all your
covered drugs.
You generally stay in
this stage
for the
rest of the
calendar year (through
December 31, 2022).
-
the next payment stage (stage 4, Catastrophic Coverage).
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| File Modified | 0000-00-00 |
| File Created | 2024-12-05 |
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