CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Defini

2022 Part D EOB Exhibit D

Exhibit D. Example of Section 3 (amounts and definitions for TrOOP and total drug costs) for a plan that offers Supplemental Drug Coverage

NOTE: The page that follows has a fictional example of Section 3 from the model Part D EOB; it is for a fictional plan that offers Supplemental Drug Coverage. Using numbers from 2022 for illustration, this section gives amounts and definitions of out- of-pocket costs and total drug costs.

The main purpose of Section 3 is to give the definitions. The monthly and year-to-date totals for a member’s out-of-pocket costs and total drug costs have already been given at the end of Chart 1 in Section 1 (Section 1 is the list of prescriptions filled during the month).

SECTION 3. Your “out-of-pocket costs” and “total drug costs” (amounts and definitions)

We’re including this Section to help you keep track of your “out-of-pocket costs” and “total drug costs” because these costs determine which drug payment stage you are in. As explained in Section 2, the payment stage you are in determines how much you pay for your prescriptions.

Your “out-of-pocket costs”

$310.60 month of Se pte mbe r, 2022

$4,356.00 ye ar-to-date (since January 2022) (This total includes $312.50 in out- of-pocket costs from when you were in a different plan earlier this year.)

DEFINITION:

“Out of pocket costs” includes:

• What you pay when you fill or refill a prescription for a covered Part D drug. (This includes payments for your drugs, if any, that are made by family or friends.)

• Payments made for your drugs by any of the following programs or organizations: “Extra Help” from Medicare, Medicare’s Coverage Gap Discount Program; Indian Health Service; AIDS drug assistance programs; most charities, and most State Pharmaceutical Assistance Programs (SPAPs).

It does not include:

• Payments made for: a) plan premiums, b) drugs not covered by our plan; c) non-Part D drugs (such as drugs you receive during a hospital stay); d) drugs covered by our plan’s Supplemental Drug Coverage; e) drugs obtained at a non-network pharmacy that does not meet our out-of-network pharmacy access policy.

• Payments made for your drugs by any of the following programs or organizations: employer or union health plans; some government-funded programs, including TRICARE and Veteran’s Administration; Worker’s Compensation, and some other programs.

Learn more . Medicare has made the rules about which types of payments count and do not count toward “out-of-pocket costs” and “total drug costs.” The definitions on this page give you only the main

rules. For details, including more about “covered Part D drugs,” see the Evidence of Coverage, our benefits booklet (for more about the Evidence of Coverage, see Section 6).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0938-0964. If you have any suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

CMS does not discriminate in its programs and activities: To request this form in an accessible format (e.g., Braille, Large Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting your plan, call: 1-800-MEDICARE.

CMS-10141

OMB Approval No. 0938-0964 (Expires 11/30/2021)