# One formulary change adds $1,586 a year An annual notice of change raises the premium by 70 cents a month and moves one maintenance drug from Tier 3 to Tier 4. For the member who fills it monthly, that is $564 a year becoming $2,150. | | | | --- | --- | | Status | EFFECTIVE JAN 1 | | Source | web:plan-notices.example/annual-notice-of-change | | Workspace | Showcase | | Tags | health-insurance, medicare-part-d, formulary, prior-authorization, cost-sharing | ## What it says **The premium is the number on the first page, and it is the smallest change in the envelope.** Alderbrook Health Plan mails this every autumn to everyone in Alderbrook Choice Rx (PDP). It is a comparison document: 2026 in one column, 2027 in the next, effective January 1. The premium is on page 1. The drug list is on page 6. The first page carries the two figures most people go looking for. The monthly premium goes from $38.40 to $39.10. The yearly deductible goes from $360 to $415. Over twelve months the premium change is $8.40. Five pages later, a table lists the drugs whose tier changed for 2027. Rimvexa 25 mg, a once-daily maintenance drug, moves from Tier 3 to Tier 4 and picks up a requirement that the plan approve it before a pharmacy can fill it. For a member who fills that prescription every month, the row is worth $1,586.00. The notice never multiplies anything, so that number appears nowhere in it. | | 2026, as it stands | 2027, as changed | | --- | --- | --- | | Monthly premium | $38.40 | $39.10 | | Yearly deductible | $360, and it applies to Tier 4 and Tier 5 only | $415, and it applies to Tier 3, Tier 4 and Tier 5 | | Tier for Rimvexa 25 mg | Tier 3, preferred brand | Tier 4, non-preferred drug | | What a 30-day fill costs | $47 flat copay | 45% of the plan's negotiated price | | Approval before the pharmacy fills it | None | Prior authorization, plus a 30-tablet quantity limit | | The January fill | $47.00 | $581.95, because the deductible comes first | | Drug costs for the year | $564.00 | $2,150.00, which is the annual out-of-pocket limit | | Premium and drug costs together | $1,024.80 | $2,619.20 | **Diagram: Four places answer one question, and the last of them was not in the envelope.** - What changes for me? [accent] - Section 2.2 cost table (identical in both columns) [neutral] - Section 2.5 drug list (Rimvexa, Tier 3 to Tier 4) [accent] - Footnote 4 (45% of the negotiated price) [neutral] - Claims summary insert ($786.00 a fill in 2026) [good] - 2027 List of Covered Drugs (referenced, not enclosed) [bad] - What changes for me? --> Section 2.2 cost table : nothing changed - What changes for me? -> Section 2.5 drug list : the tier moved - Section 2.5 drug list -> Footnote 4 : 45% of what? - Footnote 4 -> Claims summary insert : the only price mailed - Footnote 4 --> 2027 List of Covered Drugs : prices and PA rules ## How it works **Nothing in the cost table changed. The drug changed which row of it applies.** Section 2.2 prints flat copays for tiers 1 through 3 and percentages for tiers 4 and 5. Every one of those figures is the same in both years. A percentage needs a price before it becomes money, and the price is not on the page. The five steps below are the order the plan applies its own rules to a single fill. ```text Section 2.2 What You Pay for Part D Prescription Drugs (one-month supply, standard network retail pharmacy) 2026 2027 Tier 1 Preferred Generic $0 $0 Tier 2 Generic $12 $12 Tier 3 Preferred Brand $47 $47 Tier 4 Non-preferred Drug 45% 45% Tier 5 Specialty 33% 33% 4 Coinsurance amounts are calculated using the plan's negotiated price for the drug on the day the prescription is filled. Negotiated prices are not listed in this notice and may change during the plan year. ``` _A reader scanning this table for what is different finds nothing, and they are right. Both columns match. The change is three pages on, in a table that lists drugs and never mentions money._ 1. **Start from the negotiated price.** The plan's own price for a 30-day supply, $786.00 in 2026. This is the number the percentage multiplies, and the notice does not print it. It appears once in the envelope, on the claims summary, as a total for the year. 2. **Take the deductible out first.** In 2027 the drug sits in a tier the deductible reaches, so the first $415.00 of drug cost is paid in full by the member. In January that is $415.00 of the $786.00. 3. **Apply 45% to what is left.** $371.00 remains after the deductible, and 45% of it is $166.95. The January fill comes to $581.95. Every fill after that is 45% of $786.00, or $353.70. 4. **Stop at the out-of-pocket limit.** The running total crosses $2,150.00 during the June fill, which costs $153.25 rather than $353.70. July through December cost nothing. 5. **Add the year up.** $2,150.00, against $564.00 for the same twelve fills in 2026. At 45% of this price the year's total is the limit itself; the rate decides how fast the member reaches it. > **The 90-day window is stated once, in a footnote** > > Because the drug picks up a new restriction, the plan covers one temporary 30-day fill during the first 90 days of the plan year. That is January 1 to March 31, 2027. The 90 days run from the start of the year rather than from the first fill, the offer is good once, and footnote 9 on page 8 is the only place the notice says any of it. ## Key claims **The letter says most benefits are staying the same, and for most members that is true.** The notice makes a handful of claims about itself and about the plan. They hold up. One of them is doing more work than it looks like it is doing. ```text Section 2.5 Changes to Our Drug List Drug 2026 Tier 2027 Tier 2027 Restrictions ... RIMVEXA (tefenacor) 25 mg 3 4 PA, QL ... PA Prior Authorization. You or your prescriber must get approval from the plan before this drug is covered. QL Quantity Limit. Coverage is limited to 30 tablets per 30 days. ``` _Row 17. The 2026 restrictions cell for this row is blank, so both PA and QL are new. Nothing on this page mentions money._ - **Most benefits are staying the same.** Accurate about the structure. The pharmacy network, the tier 1 to 3 copays, and the tier 4 and 5 percentages are identical in both columns. What moved is which drugs sit in which tier. - **Twenty-three drugs moved to a higher tier.** Section 2.5 opens with that count, then lists the affected drugs alphabetically by brand name. Nine more were dropped from the list entirely. - **A quantity limit came with the tier move.** The same row gains QL, capped at 30 tablets per 30 days. For a once-daily prescription that is the quantity already being dispensed, so it changes nothing for this member. - **The premium comparison covers this plan only.** Section 1.1 compares Alderbrook premiums. The Part B premium and any late enrollment penalty are named as separate amounts the notice does not cover. ## Receipts **Every figure above comes from a line of the notice, or from arithmetic on one.** Quoted from the notice and from the claims summary mailed with it. The 2027 dollar amounts are arithmetic performed on these quotes, not quotes themselves. - **Claim.** The monthly premium rises by 70 cents. - Evidence: "Monthly plan premium: 2026, $38.40. 2027, $39.10." - Where: Section 1.1, Changes to Your Monthly Premium - **Claim.** Rimvexa moves from Tier 3 to Tier 4 and gains two restrictions on January 1, 2027. - Evidence: "RIMVEXA (tefenacor) 25 mg; 2026 Tier: 3; 2027 Tier: 4; 2027 Restrictions: PA, QL". The 2026 restrictions cell is blank. - Where: Section 2.5, Changes to Our Drug List, page 6, row 17 - **Claim.** Tier 4 cost sharing is a percentage, and the percentage itself did not change. - Evidence: "Tier 4 (Non-preferred Drug): you pay 45% of the total cost", printed identically in the 2026 and the 2027 column. - Where: Section 2.2, one-month supply table - **Claim.** The notice does not print the price the 45% applies to. - Evidence: "Coinsurance amounts are calculated using the plan's negotiated price for the drug on the day the prescription is filled. Negotiated prices are not listed in this notice and may change during the plan year." - Where: Section 2.2, footnote 4 - **Claim.** The deductible now reaches this drug, and it did not before. - Evidence: "Yearly deductible: 2026, $360 (Tier 4 and Tier 5 drugs only). 2027, $415 (Tier 3, Tier 4 and Tier 5 drugs)." - Where: Section 2.1, Changes to Your Deductible - **Claim.** Prior authorization means the fill waits on a decision. - Evidence: "PA, Prior Authorization. You or your prescriber must get approval from the plan before this drug is covered." - Where: Section 2.5 legend, page 7 - **Claim.** $786.00 is the 2026 price per fill, and it is the basis of every 2027 figure in this brief. - Evidence: "RIMVEXA 25 MG TAB, 12 fills, total drug cost $9,432.00, your share $564.00". $9,432.00 divided by 12 is $786.00. - Where: Enclosed 2026 Pharmacy Claims Summary, page 2 - **Claim.** The year's total is set by the out-of-pocket limit rather than by the coinsurance. - Evidence: "After your out-of-pocket costs reach $2,150 in 2027, you pay nothing for covered Part D drugs for the rest of the calendar year." - Where: Section 2.3, Stages of Your Drug Coverage - **Claim.** The temporary supply is a single 30-day fill inside 90 days. - Evidence: "If a drug you are currently taking has a new restriction in 2027, we will cover a temporary 30-day supply one time during the first 90 days of the plan year." - Where: Section 2.6, footnote 9, page 8 ## What it assumes **The notice is arranged by benefit. A reader arrives arranged by prescription.** None of these assumptions is hidden or unusual. They are what lets one letter describe a benefit structure to a hundred thousand people at once. They are also the work the reader has to do alone. Every sentence in the notice is true and most of them are plain. The difficulty is not in any sentence. It is that the letter is organized the way a plan is organized, by premium, then deductible, then tiers, then drug list, and a person reads it holding one prescription and one question. - **That you know your drug's tier.** Section 2.5 is alphabetical by brand name and marks nothing as yours. A reader who does not already know the drug is on the list has no reason to look for it there. - **That a copay and a percentage compare.** $47 and 45% sit in the same column of the same table, one line apart. One is a price. The other is a fraction of a number printed nowhere in the document. - **That the negotiated price is knowable.** Footnote 4 says the price is whatever it is on the day of the fill and may change during the year. So the cost of the drug in 2027 is unknown to the notice at the time it was mailed. - **That the reader will go and get the formulary.** The tier is in this letter. What prior authorization requires, how long a decision takes, and what a pharmacy does with a prescription while the request is pending are in a document the reader has to request or download. ## Gaps **The document that decides the number is the one not in the envelope.** Section 2.5 gives the tier and the restriction code. What the restriction requires, and what the drug will actually cost, live in material the mailing points at and does not contain. - **The 2027 List of Covered Drugs.** Referenced twice in Section 2.5 as the full formulary and as the place the restriction rules are written down. It was not mailed. The notice says it is on the plan website or available by request. - **The prior authorization criteria.** The table marks PA. Nothing in the notice says what the plan asks the prescriber for, how many days a decision takes, or whether a pharmacy can dispense while a request is open. - **The 2027 negotiated price.** Not stated anywhere. Every 2027 amount in this brief uses the 2026 price of $786.00, and footnote 4 says that price can move during the year. - **Evidence of Coverage, Chapter 6.** Cross-referenced three times, including for how the $2,150 limit is counted. Not enclosed with the mailing. - **Anything but a standard retail pharmacy.** The quoted table is the one-month, standard-network column. Section 2.2 sends preferred pharmacy and three-month supply pricing to the Evidence of Coverage rather than printing it. - **Whether a generic exists.** The notice does not say whether a generic of this drug is on the 2027 list, or what tier it would be on. That is a formulary question and the formulary is not here. Two sheets in this envelope would answer the whole thing between them. One lists what the member filled in 2026 and what each fill cost. The other lists which drugs changed tier for 2027. Nothing in the notice joins them. ## What this brief could not check - The 2027 List of Covered Drugs is referenced in Section 2.5 and was not enclosed, so this brief cannot say what the prior authorization criteria are, how long a decision takes, or whether a generic sits on a lower tier. - Every 2027 dollar figure here is arithmetic on the 2026 negotiated price of $786.00 taken from the enclosed claims summary. The notice states no 2027 price, and footnote 4 says the price can change during the plan year. - Evidence of Coverage Chapter 6 is cross-referenced three times, including for how costs count toward the $2,150 limit, and was not included with the mailing. - This brief was written by hand as a design fixture. It is modelled on real documents, but no model read a source to produce it, and its claims should not be relied on.