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Explanation of Benefits (EOB) SECTION 4: Updates to the plan’s Drug List (formulary) that will affect drugs you take

This section is used to give formulary updates that affect drugs this member is taking, i.e., any plan-covered drugs for which the member filled a prescription during the current calendar year while a member of the plan. Include updates only if they affect drugs this member is taking. Changes to the formulary from one year to the next are announced in the Annual Notice of Change (ANOC) and are not necessarily included in the Explanation of Benefits (EOB).

The purpose of this section is to give you notice and opportunity to make adjustment in your purchasing habits or to request a Coverage Determination (Formulary Exception).
  • [Use this section to give formulary updates that affect drugs the member is taking, i.e., any plan-covered drugs for which the member filled a prescription 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 2 of Section 1, but not items 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, insert the following as a replacement for all of the text that follows in this section: 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 drugs for which you filled prescriptions in [insert year] as a member of our plan.)

  • If an update is for a negative formulary change that is not a formulary maintenance change, insert: "If you are currently taking this drug, this change will not affect your coverage for this drug for the rest of the plan year."]]



About the Drug List and our updates

[Insert plan name] has a "List of Covered Drugs (Formulary)" or "Drug List" for short. If you need a copy, the Drug List on our website ([insert website URL]) is always the most current. Or call [insert plan name] Member Services (phone numbers are on the cover of this summary).

The Drug List tells which Part D prescription drugs are covered by the plan. It also tells which of the [insert number of cost-sharing tiers] "cost-sharing tiers" each drug is in and whether there are any restrictions on coverage for a drug.

During the year, with Medicare approval, we may make changes to our Drug List. We may add new drugs, remove drugs, and add or remove restrictions on coverage for drugs. We are also allowed to change drugs from one cost-sharing tier to another.
  • Some changes to the Drug List may happen immediately:
    • [Plans that otherwise meet the requirements to immediately substitute generic drugs for brand name drugs (or to increase tier sharing or add more restrictions to access to brand name drugs) insert the following bullet.] We may immediately replace a brand name drug with a new generic that will appear on the same or lower cost-sharing tier and with the same or lower restrictions. Or we may immediately add the new generic and add new restrictions to the brand name drug or move it to a different-cost sharing tier.
    • We will immediately remove drugs from our Drug List for safety reasons or when manufacturers remove them from the market.
  • For all other changes, you will have at least 30 days’ notice before any changes take effect.



Updates that affect drugs you take

The list that follows tells only about updates to the Drug List that change the coverage or cost of drugs you take.

(For purposes of this update list, "drugs you take" means any plan-covered drugs for which you filled prescriptions in [insert year] as a member of our plan.)

[Below we show model language for reporting several common types of changes to the Drug List. Use it 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 provide additional explanation of changes if desired, and suggest specific drugs that might be suitable alternatives. To report changes for which model language is not supplied, use the model language shown below as a guide.]

[Insert name of step therapy drug; plans may also insert information about the strength or form in which the drug is dispensed (e.g., tablets, injectable, etc.)]

  • Date and type of change: Beginning [insert effective date of the 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 will cover [name of step therapy drug]. This requirement encourages you to try another drug that is less costly, yet just as safe and effective as [insert name of step therapy drug]. If [insert either: this other drug does not OR the other drugs do not] work for you, the plan will then cover [insert name of step therapy drug].

  • Note: See the information later in this section that tells "What you and your doctor can do." [If applicable, plans may insert information that identifies 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 restrictions on coverage. They are used in similar ways as [name of step therapy drug] and they are on a lower cost-sharing tier.)"]


[Insert name of quantity limits drug; plans may also insert information about the strength or form in which the drug is dispensed (e.g., tablets, injectable, etc.)]

  • Date and type of change: Beginning [insert effective date of the change], there will be a new limit on the amount of the drug you can have: [insert description of how the quantity will be limited].

  • Note: See the information below that tells "What you and your doctor can do."


[Insert name of prior authorization drug; plans may also insert information about the strength or form in which the drug is dispensed (e.g., tablets, injectable, etc.)]

  • Date and type of change: Beginning [insert effective date of the change], "prior authorization" will be required for this drug. This means you or your doctor need to get approval from the plan before we will agree to cover the drug for you.

  • Note: See the information later in this section that tells "What you and your doctor can do." [Plans may insert more explanation if desired, for example, "Your choices include asking for prior authorization in order to continue having this drug covered or changing to a different drug.]


[The below language with appropriate modifications can be used to provide notice of immediate generic substitutions by Part D sponsors meeting the requirements, as well as other generic changes as long as the notice is provided to the enrollee within required timeframes.]

[Insert name of brand-name drug that has been or will be replaced with generic or whose preferred or tiered cost-sharing or restrictions 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.)]

  • Date and type of change: Effective [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. 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 are [insert either: "replacing" OR "replaced" [name of brand name drug] OR [insert as applicable: "changed" OR "are changing" "cost-sharing" OR "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 now available. [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" tier than [name of brand name drug], the drug it [insert either: "is replacing" OR "replaced"] [insert if generic drug is on a lower tier: (tier [insert cost-sharing tier number or name for the brand name drug that is being replaced.]) The amount you will pay for [insert name of generic drug] depends on which drug payment stage you are in when you fill the prescription. To find out how much you will pay for the [insert name of generic drug], please call us at [insert plan name] Member Services (our phone numbers and calling hours are on the cover).

  • If your prescriber believes this generic drug is not right for you due to your medical condition, you or your prescriber can ask us to make an exception. See the information later in this section that tells "What you and your doctor can do."

  • Note: [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 cost-sharing tier than [insert name of brand-name drug to be replaced with generic] (tier [insert cost-sharing tier number or name for the replacement generic drug])."


[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.)]

  • Date and type of change: Effective [insert effective date of the change], [insert description of the change, for example, "the brand-name drug [insert name of drug for which cost-sharing will increase] will move from tier 2 to a higher cost-sharing tier (tier 3)."] The amount you will pay for this drug depends on which drug payment stage you are in when you fill the prescription. To find out how much you will pay, please call us at [insert plan name] Member Services (our phone numbers and calling hours are on the cover).

  • Note: See the information later in this section that tells "What you and your doctor can do." [Plans may add more information if desired, for example, "(You and your doctor may want to consider trying a lower cost generic drug, [insert name of lower-cost generic drug], which is in cost-sharing tier [insert number or name of cost-sharing tier].)"


What you and your doctor can do

We are telling you about these changes now, so that you and your doctor will have time (at least 30 days) to decide what to do.

Depending on the type of change, there may be different options to consider. For example:
  • Perhaps you can find a different drug covered by the plan that might work just as well for you.

  • You can call us at [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 the plan to make an exception for you. This means asking us to agree that the upcoming change in coverage or cost-sharing tier of a drug does not apply to you.
    • Your doctor will need to tell us why making an exception is medically necessary for you.

    • To learn what you must do to ask for an exception, see the Evidence of Coverage that we sent to you. [MA-PD plans insert: Look for Chapter 9, What to do if you have a problem or complaint.] [PDP plans insert: Look for Chapter 7, What to do if you have a problem or complaint.]

    • (Section 6 of this monthly summary tells how to get a copy of the Evidence of Coverage if you need it.)

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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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