Explanation of Benefits (EOB) SECTION 2: Which ’drug payment stage’ are you in?

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Explanation of Benefits (EOB) SECTION 2: Which ’drug payment stage’ are you in?
This section shows which drug coverage payment stage you are in. The four stages of coverage are deductible, initial coverage, coverage gap, and catastrophic coverage.

All four stages will always be shown in this section of the document and your current stage will be highlighted. The Language in Section 2 is customized to fit the payment stage the member is in. Within each stage, there are wording variations. These include variations for plan design (e.g., deductible vs. brand-name/tier level only deductible vs. non-deductible, partial coverage during the Coverage Gap) and for member receiving the Low-Income Subsidy (LIS) (also known as "Extra Help") and non-LIS members. Examples will be shown for both LIS and non-LIS members.

SECTION 2. Which "drug payment stage" are you in?

This chart reflects the Initial Deductible stage for non-Low-Income Subsidy (LIS) Members
As shown below, your prescription drug coverage has "drug payment stages." How much you pay for a 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 1 Yearly Deductible [If the plan has a deductible for all tiers, insert the following three bullets.] You begin in this payment stage when you fill your first prescription of the calendar year. During this stage, you (or others on your behalf) pay the full cost of your drugs. You generally stay in this stage until you (or others on your behalf) have paid $[deductible amount] for your drugs ($[ deductible amount] is the amount of your deductible). As of [end date for the month] you have paid $[year-to-date Total Drug Costs] 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 [brand-name/tier level] drugs. You generally pay the full cost of your [brand-name/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 have paid $*[insert year-to-date Deductible Drug Costs]* for your drugs in the deductible.	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. [Insert if applicable: After you (or others on your behalf) have met your [brand-name/tier level] deductible, the plan pays its share of the cost of your [brand-name/tier level] drugs and you (or others on your behalf) pay your share of the cost.] You generally stay in this stage until the amount of your year-to-date "total drug costs" (see Section 3) reaches $[insert initial coverage limit]. [If the plan has a brand-name/tier level deductible, insert the following bullet.] As of [insert end date for the month] your year-to-date "total drug costs" were $[insert year-to-date Total Drug Costs]. (See definitions in Section 3.)	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 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-pocket costs" (see Section 3) reaches $8000. When this happens, 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, 2024).
What happens next?
Once you (or others on your behalf) have paid an additional $______ for your drugs, you move to the next payment stage (stage 2, Initial Coverage).

The next chart reflects the Initial Coverage stage for non-Low-Income Subsidy (LIS) Members

Notes on the Initial Coverage column:
If your plan does not have a Deductible stage, the Initial Coverage column will begin with the text:
You begin in this payment stage when you fill your first prescription of the year. During this stage, .....

Notes on the Deductible column:
The text shown in the deductible column of the chart is the standard text If the plan has a deductible for all tiers.

If the plan has no deductible, the deductible column text is replaced with: (Because there is no deductible for the plan, this payment stage does not apply to you.)]

If the plan has a brand-name/tier level deductible, the following two bullets will appear in the deductible column.

• During this payment stage, you (or others on your behalf) pay the full cost of your [brand-name/tier level] drugs.

• You generally pay the full cost of your [brand-name/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.) This note applies to all of the charts to follow.

	You are in this stage:
STAGE 1 Yearly Deductible [If the plan has no deductible, replace the text in this cell with: (Because there is no deductible for the plan, this payment stage does not apply to you.) ] [If the plan has a brand-name/tier level deductible, insert the following two bullets.] During this payment stage, you (or others on your behalf) pay the full cost of your [brand-name/tier level] drugs. You generally pay the full cost of your [brand-name/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.) [If the plan has a deductible for all tiers, insert the following two bullets.] You begin in this payment stage when you fill your first prescription of the year. During this stage, you (or others on your behalf) pay the full cost of your drugs. You generally stay in this stage until you have paid $[insert deductible amount] for your drugs ($[insert deductible amount] is the amount of your deductible). Then you move to payment stage 2, Initial Coverage.	STAGE 2 Initial Coverage [Insert either: You begin in this payment stage when you fill your first prescription of the year. During this OR 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 [Insert if applicable: After you (or others on your behalf) have met your [brand-name/tier level] deductible, the plan pays its share of the cost of your [brand-name/tier level] drugs and you (or others on your behalf) pay your share of the cost.] You generally stay in this stage until the amount of your year-to-date "total drug costs" (see Section 3) reaches $[insert initial coverage limit]. As of [insert end date for the month] your year-to-date "total drug costs" were $[insert year-to-date Total Drug Costs]. (See definitions in Section 3.)	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 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-pocket costs" (see Section 3) reaches $8000. When this happens, 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, 2024).
	What happens next?
	Once you (or others on your behalf) have an additional $______ in "total drug costs," you move to the next payment stage (stage 3, Coverage Gap).

The next chart reflects the Coverage Gap stage for non-Low-Income Subsidy (LIS) Members

		You are in this stage:
STAGE 1 Yearly Deductible [If the plan has no deductible, replace the text in this cell with: (Because there is no deductible for the plan, this payment stage does not apply to you.) ] [If the plan has a brand-name/tier level deductible, insert the following two bullets.] During this payment stage, you (or others on your behalf) pay the full cost of your [brand-name/tier level] drugs. You generally pay the full cost of your [brand-name/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.) [If the plan has a deductible for all tiers, insert the following two bullets.] You begin in this payment stage when you fill your first prescription of the year. During this stage, you (or others on your behalf) pay the full cost of your drugs. You generally stay in this stage until you have paid $[insert deductible amount] for your drugs ($[insert deductible amount] is the amount of your deductible). Then you move to payment stage 2, Initial Coverage.	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. [Insert if applicable: After you (or others on your behalf) have met your [brand-name/tier level] deductible, the plan pays its share of the cost of your [brand-name/tier level] drugs and you (or others on your behalf) pay your share of the cost.] You generally stay in this stage until the amount of your year-to-date "total drug costs" (see Section 3) reaches $[insert initial coverage limit]. Then you move to payment stage 3, Coverage Gap.	You generally stay in this stage until the amount of your year-to-date "out-of-pocket costs" (see Section 3) reaches $8000. As of [insert end date for the month] your year-to-date "total drug costs" were $[insert year-to-date Total Drug Costs]. (See definitions in Section 3.)	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, 2024).
		What happens next?
		Once you (or others on your behalf) have paid an additional $______ in "out-of-pocket costs," you move to the next payment stage (stage 4, Catastrophic Coverage).

The next chart reflects the Catastrophic Coverage stage for non-Low-Income Subsidy (LIS) Members

			You are in this stage:
STAGE 1 Yearly Deductible [If the plan has no deductible, replace the text in this cell with: (Because there is no deductible for the plan, this payment stage does not apply to you.) ] [If the plan has a brand-name/tier level deductible, insert the following two bullets.] During this payment stage, you (or others on your behalf) pay the full cost of your [brand-name/tier level] drugs. You generally pay the full cost of your [brand-name/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.) [If the plan has a deductible for all tiers, insert the following two bullets.] You begin in this payment stage when you fill your first prescription of the year. During this stage, you (or others on your behalf) pay the full cost of your drugs. You generally stay in this stage until you have paid $[insert deductible amount] for your drugs ($[insert deductible amount] is the amount of your deductible). Then you move to payment stage 2, Initial Coverage.	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. [Insert if applicable: After you (or others on your behalf) have met your [brand-name/tier level] deductible, the plan pays its share of the cost of your [brand-name/tier level] drugs and you (or others on your behalf) pay your share of the cost.] You generally stay in this stage until the amount of your year-to-date "total drug costs" (see Section 3) reaches $[insert initial coverage limit]. Then you move to payment stage 3, Coverage Gap.	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 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-pocket costs" (see Section 3) reaches $8000. When this happens, 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. In this 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 payment stage, Catastrophic Coverage, for the rest of the calendar year (through December 31, [insert year]).

The following version of Section 2 is for members with LIS who are in the initial payment stage

Member with LIS (or "Extra Help") jump over the Coverage Gap stage. Once they stay in the Initial Coverage stage until they have met the TrOOP limit; then they move directly to stage 4, Catastrophic Coverage (skipping the Coverage Gap).

STAGE 1 Yearly Deductible
[If the plan has a deductible and the EOB is for a member with full LIS, insert the following text as a replacement for the other text in the deductible column: (Because you are receiving "Extra Help" from Medicare, this payment stage does not apply to you.)]

[If the plan has a brand-name/tier level deductible, insert the following two bullets.]

• During this payment stage, you (or others on your behalf) pay the full cost of your [brand-name/tier level] drugs.

• You generally pay the full cost of your [brand-name/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.)

[If the plan has a deductible for all tiers, insert the following bullet.]

• You begin in this payment stage when you fill your first prescription of the year. During this stage, you (or others on your behalf) pay the full cost of your drugs. Then you move to payment stage 2, Initial Coverage.

STAGE 2 Initial Coverage
• [Insert either: You begin in this payment stage when you fill your first prescription of the year. During this OR 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.

• [Insert if applicable: After you (or others on your behalf) have met your [brand-name/tier level] deductible, the plan pays its share of the cost of your [brand-name/tier level] drugs and you (or others on your behalf) pay your share of the cost.]

• You generally stay in this stage until the amount of your year-to-date "out-of-pocket costs" reaches $[insert TrOOP limit]. As of [insert end date of month] your year-to-date "out-of-pocket costs" was $[insert year-to-date TrOOP] (see definitions in Section 3).

Navigate the Explanation of Benefits document:

SECTION 1: Your prescriptions during the past month

SECTION 2: Which "drug payment stage" are you in?

SECTION 3: Your "out-of-pocket costs" and "total drug costs"

SECTION 4: Updates to the plan's Drug List that will affect drugs you take

SECTION 5: If you see mistakes on this summary or have questions, what should you do?

SECTION 6: Important things to know about your drug coverage and your rights

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