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

Chart 4: "Changes to our Drug List that affect drugs you take " 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 the member filled a prescription for 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 included in the ANOC and do not need to be included in the EOB.) This section should include such updates for covered Part D drugs and drugs covered under a supplemental benefit listed in Charts 1 and 1A of Section 1, but not those 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.)