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

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])."