Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
Annual Notice of Change and Evidence of Coverage for Applicable Integrated Plans in States that Require Integrated Materials (CMS-10824)
CH 6 EOC
Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
OMB: 0938-1444
<Plan name> MEMBER HANDBOOK
Chapter 6: What you pay for your Medicare and <Medicaid program name> drugs
Introduction
This chapter tells what you pay for your outpatient drugs. By “drugs,” we mean:
Medicare Part D drugs, and
Drugs and items covered under Medicaid, and
[Insert if applicable: Drugs and items covered by our plan as additional benefits.]
Because you’re eligible for <Medicaid program name>, you get Extra Help from Medicare to help pay for your Medicare Part D drugs. [Plans who have $0 cost-sharing for all Medicare Part D drugs should remove the remaining language in this paragraph.] We [insert as appropriate: have included or sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Member Services and ask for the “LIS Rider.”
Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.” |
Other key terms and their definitions appear in alphabetical order in the last chapter of this Member Handbook.
To learn more about drugs, you can look in these places:
Our List of Covered Drugs.
We call this the Drug List. It tells you:
which drugs we pay for
[Plans that don’t have cost-sharing in any tier or don’t have tiers can omit this bullet.] which of the <number of tiers> tiers each drug is in
if there are any limits on the drugs
if you need a copy of our Drug List, call Member Services. You can also find the most current copy of our Drug List on our website at <URL>.
Chapter 5 of this Member Handbook.
It tells how to get your outpatient drugs through our plan.
It includes rules you need to follow. It also tells which types of drugs our plan doesn’t cover.
When you use the plan’s “Real Time Benefit Tool” to look up drug coverage (refer to Chapter 5, Section B2), the cost shown is an estimate of the out-of-pocket costs you’re expected to pay. You can call [insert if applicable: your care coordinator] or Member Services for more information.
Our Provider and Pharmacy Directory.
In most cases, you must use a network pharmacy to get your covered drugs. Network pharmacies are pharmacies that agree to work with us.
The Provider and Pharmacy Directory lists our network pharmacies. Refer to Chapter 5 of this Member Handbook for more information about network pharmacies.
[Plans with no cost-sharing for all outpatient drugs, delete Sections D, E, and F, and change section G to section D.]
[Plans should refer to other parts of the Member Handbook using the appropriate chapter number and section. For example, "refer to Chapter 9, Section A." An instruction [insert reference, as applicable] appears with many cross references throughout the Member Handbook. Plans can always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]
[Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]
Table of Contents
A. The Explanation of Benefits (EOB) 4
B. How to keep track of your drug costs 5
C3. Getting a long-term supply of a drug 8
D. Stage 1: The Initial Coverage Stage [Plans with one coverage stage should delete this section] 10
D2. Getting a long-term supply of a drug 11
D4. End of the Initial Coverage Stage 12
G. What you pay for Part D vaccines 14
G1. What you need to know before you get a vaccine 14
G2. What you pay for a vaccine covered by Medicare Part D 15
[Plans with a single payment stage (i.e., no cost-sharing differences between the Initial Coverage Stage and the Catastrophic Coverage Stage), modify this section as necessary.]
Our plan keeps track of your drug costs and the payments you make when you get prescriptions at the pharmacy. We track two types of costs:
Your out-of-pocket costs. This is the amount of money you, or others on your behalf, pay for your prescriptions. This includes what you paid when you got a covered Part D drug, any payments for your drugs made by family or friends, any payments made for your drugs by Extra Help from Medicare, employer or union health plans, Indian Health Service, AIDS drug assistance programs, charities, and most State Pharmaceutical Assistance Programs (SPAPs).
Your total drug costs. This is the total of all payments made for your covered Part D drugs. It includes what our plan paid, and what other programs or organizations paid for your covered Part D drugs.
When you get drugs through our plan, we send you a summary called the Explanation of Benefits. We call it the EOB for short. The EOB isn’t a bill. The EOB has more information about the drugs you take [insert, as applicable: such as increases in price and other drugs with lower cost-sharing that may be available. You can talk to your prescriber about these lower cost options]. The EOB includes:
Information for the month. The summary tells what drugs you got for the previous month. It shows the total drug costs, what we paid, and what you and others paid for you.
Totals for the year since January 1. This shows the total drug costs and total payments for your drugs since the year began.
Drug price information. This is the total price of the drug and changes in the drug price since the first fill for each prescription claim of the same quantity.
Lower cost alternatives. When applicable, information about other available drugs with lower cost-sharing for each prescription.
We offer coverage of drugs not covered under Medicare.
Payments made for these drugs don’t count towards your total out-of-pocket costs.
[Insert only if the plan pays for OTC drugs as part of its administrative costs under Medicare Part D, rather than as a Medicaid benefit: We also pay for some over-the-counter drugs. You don’t have to pay anything for these drugs.]
To find out which drugs our plan covers, refer to our Drug List. [Insert if applicable: In addition to the drugs covered under Medicare, some prescription and over-the-counter drugs are covered under <Medicaid program name>. These drugs are included in the Drug List.]
To keep track of your drug costs and the payments you make, we use records we get from you and from your pharmacy. Here is how you can help us:
Show your Member ID Card every time you get a prescription filled. This helps us know what prescriptions you fill and what you pay.
Give us copies of receipts for covered drugs that you paid for. You can ask us to pay you back for [insert if plan has cost-sharing: our share of the cost of] the drug.
Here are examples of when you should give us copies of your receipts:
When you buy a covered drug at a network pharmacy at a special price or use a discount card that isn’t part of our plan’s benefit.
When you pay a copay for drugs that you get under a drug maker’s patient assistance program.
When you buy covered drugs at an out-of-network pharmacy.
When you pay the full price for a covered drug under special circumstances.
For more information about asking us to pay you back for [insert if plan has cost-sharing: our share of the cost of] a drug, refer to Chapter 7 of this Member Handbook.
Payments made by certain other people and organizations also count toward your out-of-pocket costs. For example, [plans with an SPAP include: payments made by a State Pharmaceutical Assistance Program], an AIDS drug assistance program (ADAP), the Indian Health Service, and most charities count toward your out-of-pocket costs. [Plans should delete the rest of this paragraph if they cover all Medicare Part D drugs at $0 cost-sharing:] This can help you qualify for catastrophic coverage. When you reach the Catastrophic Coverage Stage, our plan pays all of the costs of your Medicare Part D drugs for the rest of the year.
When you get an EOB in the mail, make sure it’s complete and correct.
Do you recognize the name of each pharmacy? Check the dates. Did you get drugs that day?
Did you get the drugs listed? Do they match those listed on your receipts? Do the drugs match what your doctor prescribed?
What if you find mistakes on this summary?
If something is confusing or doesn’t seem right on this EOB, please call us at <plan name> Member Services. [If applicable: You can also find answers to many questions on our website: <URL>.]
What about possible fraud?
If this summary shows drugs you’re not taking or anything else that seems suspicious to you, please contact us.
Call us at <plan name> Member Services.
Or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free.
[Plans can also insert additional State-based resources for reporting fraud.]
If you think something is wrong or missing, or if you have any questions, call Member Services. [Plans that allow members to manage this information online can describe that option here.] Keep these EOBs. They’re an important record of your drug expenses.
[Plans with two payment stages, insert: Drug Payment Stages for Medicare Part D drugs] [Plans with one payment stage, insert: You pay nothing for a one-month [insert if applicable: or long-term] supply of drugs]
[Plans with one payment stage (i.e., those with no cost-sharing for all Medicare Part D drugs), include the following sentence: With our plan, you pay nothing for covered drugs if you follow our rules.]
[Plans with two payment stages (i.e., those charging LIS cost-shares in the initial coverage stage), include the following paragraph and table.]
There are two payment stages for your Medicare Part D drug coverage under our plan. How much you pay for each prescription depends on your level of Extra Help and which stage you’re in when you get a prescription filled or refilled. These are the two stages:
Stage 1: Initial Coverage Stage |
Stage 2: Catastrophic Coverage Stage |
During this stage, we pay part of the costs of your drugs, and you pay your share. Your share is called the copay. You begin in this stage when you fill your first prescription of the year. |
During this stage, we pay all of the costs of your drugs through <end date>. You begin this stage when you’ve paid a certain amount of out-of-pocket costs. |
[Plans with one payment stage (i.e., those with no cost-sharing for all Medicare Part D drugs), include the following information up to Section D.]
[Plans with tiers must provide an explanation of tiers; refer to the examples below but plans should modify information based on the tiering structure. Plans without tiers should omit information on tiers.]
[Plans that have cost-sharing in any tier include: Cost-sharing tiers are groups of drugs with the same copay. Every drug on our Drug List is in one of <number of tiers> cost-sharing tiers. In general, the higher the tier number, the higher the copay. To find the cost-sharing tiers for your drugs, refer to our Drug List.
If a plan has no cost-sharing for one or more tiers of drugs, the plan should modify the cost-sharing information accordingly. Include examples such as the following:
Tier 1 drugs have the lowest copay. They may be generic drugs or non-Medicare drugs that are covered by Medicaid. The copay is from <amount> to <amount>, depending on your income.
Tier 2 drugs have a medium copay. They’re brand name drugs. The copay is from <amount> to <amount>, depending on your income.
Tier 3 drugs have the highest copay. The copay is <amount>.]
[Plans that don’t have drug tiers should omit this section.]
How much you pay for a drug depends on whether you get the drug from:
a network pharmacy, or
an out-of-network pharmacy. In limited cases, we cover prescriptions filled at out-of-network pharmacies. Refer to Chapter 5 of this Member Handbook to find out when we do that.
[Plans without mail-order pharmacies should delete this bullet.] Our plan’s mail-order pharmacy.
Refer to Chapter 9 of this Member Handbook to learn about how to file an appeal if you’re told a drug won’t be covered. To learn more about these pharmacy choices, refer to Chapter 5 of this Member Handbook and our Provider and Pharmacy Directory.
[Plans that don’t offer extended supplies, delete this section.]
For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is [insert if applicable: up to] a <number of days>-day supply. [Plans with cost-sharing, insert: It costs you the same as a one-month supply.] [Plans with no cost-sharing, insert: There’s no cost to you for a long-term supply.]
For details on where and how to get a long-term supply of a drug, refer to Chapter 5 of this Member Handbook or our Provider and Pharmacy Directory.
[Plans that have copays must include the following language. Other plans should delete this section.] You may pay a copay when you fill a prescription. If your covered drug costs less than the copay, you pay the lower price.
Contact Member Services to find out how much your copay is for any covered drug.
Your share of the cost when you get a one-month [insert if applicable: or long-term] supply of a covered drug from:
[Plans can delete columns and modify the table as necessary to reflect the plan’s prescription drug coverage. Include all possible copay amounts (not just the high/low ranges) – i.e., all three possible copay amounts for a tier in which LIS cost-sharing applies – in the chart, as well as a statement that the copays for drugs can vary based on the level of Extra Help the member gets (if the plan charges copays for any of its Medicare Part D drugs). Modify the chart as necessary to include $0 copays for non-Medicare covered drugs.]
[Plans should add or remove tiers as necessary. If mail-order isn’t available for certain tiers, plans should insert the following text in the cost-sharing cell: Mail-order isn’t available for drugs in [insert tier].]
|
A network pharmacy
A one-month or up to a <number of days>-day supply |
Our plan’s mail-order service
A one-month or up to a <number of days>-day supply |
A network long-term care pharmacy
Up to a <number of days>-day supply |
An out-of-network pharmacy
Up to a <number of days>-day supply. Coverage is limited to certain cases. Refer to Chapter 5 of this Member Handbook for details. |
Cost-sharing Tier 1 ([Insert description; e.g., “generic drugs.”]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
Cost-sharing Tier 2 ([Insert description.]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
Cost-sharing Tier 3 ([Insert description.]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
Cost-sharing Tier 4 ([Insert description.]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
For information about which pharmacies can give you long-term supplies, refer to our plan’s Provider and Pharmacy Directory.
During the Initial Coverage Stage, we pay a share of the cost of your covered drugs, and you pay your share. Your share is called the copay. The copay depends on the cost-sharing tier the drug is in and where you get it.
[Plans must provide an explanation of tiers; refer to the examples below. Plans have flexibility to describe their tier model as appropriate. Plans can also edit or delete language regarding Medicaid based on Medicaid coverage.]
[Plans that have cost-sharing in any tier include: Cost-sharing tiers are groups of drugs with the same copay. Every drug on our plan’s Drug List is in one of <number of tiers> cost-sharing tiers. In general, the higher the tier number, the higher the copay. To find the cost-sharing tiers for your drugs, refer to our Drug List.
Tier 1 drugs have the lowest copay. They may be generic drugs or non-Medicare drugs that <Medicaid program name> covers. The copay is from <amount> to <amount>, depending on your income.
Tier 2 drugs have a medium copay. They’re brand name drugs. The copay is from <amount> to <amount>, depending on your income.
Tier 3 drugs have the highest copay. The copay is <amount>.]
How much you pay for a drug depends on if you get the drug from:
A network retail pharmacy or
[Plans with retail network pharmacies that offer preferred cost-sharing insert: A network retail pharmacy that offers preferred cost-sharing. Costs may be less at pharmacies that offer preferred cost-sharing.]
An out-of-network pharmacy. In limited cases, we cover prescriptions filled at out-of-network pharmacies. Refer to Chapter 5 of this Member Handbook to find out when we do that.
[Plans with mail-order pharmacies insert: Our plan’s mail-order pharmacy.]
To learn more about these choices, refer to Chapter 5 of this Member Handbook and to our Provider and Pharmacy Directory.
[Plans that don’t offer extended supplies, delete the following two paragraphs:]
For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is [insert if applicable: up to] a <number of days>-day supply. [Plans with cost-sharing, insert: It costs you the same as a one-month supply.] [Plans with no cost-sharing, insert: There’s no cost to you for a long-term supply.]
For details on where and how to get a long-term supply of a drug, refer to Chapter 5 of this Member Handbook or our plan’s Provider and Pharmacy Directory.
During the Initial Coverage Stage, you may pay a copay each time you fill a prescription. If your covered drug costs less than the copay, you pay the lower price.
Contact Member Services to find out how much your copay is for any covered drug.
Your share of the cost when you get a one-month [insert if applicable: or long-term] supply of a covered drug from:
[Plans can add or delete columns and modify the table as necessary to reflect the plan’s prescription drug coverage. Include all possible copay amounts (not just the high/low ranges) – i.e., all three possible copay amounts for a tier in which LIS cost-sharing applies – in the chart, as well as a statement that the copays for drugs can vary based on the level of Extra Help the member gets.]
[Plans should add or remove tiers as necessary. Plans should remove references to “cost-sharing” as appropriate. If mail-order isn’t available for certain tiers, plans should insert the following text in the cost-sharing cell: Mail-order isn’t available for drugs in <tier>.]
|
A network pharmacy
A one-month or up to a <number of days>-day supply |
Our plan’s mail-order service
A one-month or up to a <number of days>-day supply |
A network long-term care pharmacy
Up to a <number of days>-day supply |
An out-of-network pharmacy
Up to a <number of days>-day supply. Coverage is limited to certain cases. Refer to Chapter 5 of this Member Handbook for details. |
Cost-sharing Tier 1 ([Insert description; e.g., “generic drugs.”]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
Cost-sharing Tier 2 ([Insert description.]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
Cost-sharing Tier 3 ([Insert description.]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
Cost-sharing Tier 4 ([Insert description.]) |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
[Insert copay(s).] |
For information about which pharmacies can give you long-term supplies, refer to our Provider and Pharmacy Directory.
The Initial Coverage Stage ends when your total out-of-pocket costs reach $<TrOOP amount>. At that point, the Catastrophic Coverage Stage begins. We cover all your drug costs from then until the end of the year.
[Insert if applicable: We offer additional drugs that aren’t normally covered in a Medicare Drug Plan. Payments made for these drugs don’t count toward your out-of-pocket costs.]
Your EOB helps you keep track of how much you’ve paid for your drugs during the year. We let you know if you reach the [insert as applicable: $<TrOOP amount>] limit. Many people don’t reach it in a year.
When you reach the out-of-pocket limit of $<TrOOP amount> for your drugs, the Catastrophic Coverage Stage begins. You stay in the Catastrophic Coverage Stage until the end of the calendar year. During this stage, you pay nothing for your Part D covered drugs. [Plans that cover Medicaid drugs or excluded drugs under an enhanced benefit with cost-sharing in this stage, insert the following as applicable and adjust as needed: For Medicaid drugs and excluded drugs under our enhanced benefit you pay <insert copay amount>.]
Your drug costs if your doctor prescribes less than a full month’s supply [Plans with no Medicare Part D drug cost-sharing should delete this section]
[Insert as appropriate: Usually or In some cases], you pay a copay to cover a full month’s supply of a covered drug. However, your doctor can prescribe less than a month’s supply of drugs.
There may be times when you want to ask your doctor about prescribing less than a month’s supply of a drug (for example, when you’re trying a drug for the first time).
If your doctor agrees, you don’t pay for the full month’s supply for certain drugs.
When you get less than a month’s supply of a drug, the amount you pay is based on the number of days of the drug that you get. We calculate the amount you pay per day for your drug (the “daily cost-sharing rate”) and multiply it by the number of days of the drug you get.
[Plans can revise the information in this paragraph to reflect the appropriate number of days for their one-month supplies as well as the cost-sharing amount in the example for the current year.] Here’s an example: Let’s say the copay for your drug for a full month’s supply (a 30-day supply) is $1.35. This means that the amount you pay for your drug is less than $0.05 per day. If you get a seven days’ supply of the drug, your payment is less than $.05 per day multiplied by seven days, for a total payment less than $0.35.
Daily cost-sharing allows you to make sure a drug works for you before you pay for an entire month’s supply.
You can also ask your provider to prescribe less than a full month’s supply of a drug to help you:
Better plan when to refill your drugs,
Coordinate refills with other drugs you take, and
Take fewer trips to the pharmacy.
[Plans can revise this section as needed.]
Important message about what you pay for vaccines: Some vaccines are considered medical benefits and are covered under Medicare Part B. Other vaccines are considered Medicare Part D drugs. You can find these vaccines listed in our Drug List. Our plan covers most adult Medicare Part D vaccines at no cost to you. Refer to your plan’s Drug List or contact Member Services for coverage and cost-sharing details about specific vaccines.
There are two parts to our coverage of Medicare Part D vaccines:
The first part is for the cost of the vaccine itself.
The second part is for the cost of giving you the vaccine. For example, sometimes you may get the vaccine as a shot given to you by your doctor.
[Plans can revise this section as needed.]
We recommend that you call Member Services if you plan to get a vaccine.
We can tell you about how our plan covers your vaccine [insert if the plan has cost-sharing: and explain your share of the cost].
[Insert if applicable: We can tell you how to keep your costs down by using network pharmacies and providers. Network pharmacies and providers agree to work with our plan. A network provider works with us to ensure that you have no upfront costs for a Medicare Part D vaccine.]
[Plans that don’t charge any Medicare Part D vaccine copays can delete the following section.]
What you pay for a vaccine depends on the type of vaccine (what you’re being vaccinated for).
Some vaccines are considered health benefits rather than drugs. These vaccines are covered at no cost to you. To learn about coverage of these vaccines, refer to the Benefits Chart in Chapter 4 of this Member Handbook.
Other vaccines are considered Medicare Part D drugs. You can find these vaccines on our plan’s Drug List. [Insert if applicable: You may have to pay a copay for Medicare Part D vaccines.] If the vaccine is recommended for adults by an organization called the Advisory Committee on Immunization Practices (ACIP) then the vaccine will cost you nothing.
Here are three common ways you might get a Medicare Part D vaccine.
You get the Medicare Part D vaccine and your shot at a network pharmacy.
For most adult Part D vaccines, you’ll pay nothing.
For other Part D vaccines, you pay [insert as applicable: nothing or a copay] for the vaccine.
You get the Medicare Part D vaccine at your doctor’s office, and your doctor gives you the shot.
You pay [insert as applicable: nothing or a copay] to the doctor for the vaccine.
Our plan pays for the cost of giving you the shot.
The doctor’s office should call our plan in this situation so we can make sure they know you only have to pay [insert as applicable: nothing or a copay] for the vaccine.
You get the Medicare Part D vaccine medication at a pharmacy, and you take it to your doctor’s office to get the shot.
For most adult Part D vaccines, you’ll pay nothing for the vaccine itself.
For other Part D vaccines, you pay [insert as applicable: nothing or a copay] for the vaccine.
Our plan pays for the cost of giving you the shot.
[Insert any additional information about your coverage of vaccines.]
If
you have questions, please call <plan name> at <toll-free
phone and TTY numbers>, <days and hours of operation>. The
call is free. For more information, visit <URL>.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | National Template for Dual Eligible Special Needs Plans Model Member Handbook Chapter 6 |
| Subject | D-SNP CY 2027 Model MH Chapter 6 |
| Author | CMS/MMCO |
| File Modified | 0000-00-00 |
| File Created | 2025-12-17 |
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