Exhibit 1.3_Likely to Benefit Instructions_FINAL

Instructions

Medicare Prescription Payment Plan Likely to Benefit Notice (CMS-XXXXX)

Under sections 1860D–2(b)(2)(E)(v)(III)(dd) and 1860D–2(b)(2)(E)(v)(III)(ee) of the Act, Part D sponsors must have a mechanism to notify a pharmacy when a Part D enrollee incurs OOP costs with respect to covered Part D drugs that make it likely the enrollee may benefit from participating in the program and must provide that the pharmacy, after receiving such a notification, informs the enrollee about the program. Additionally, as outlined in the part two guidance for the Medicare Prescription Payment Plan, CMS is requiring Part D sponsors to undertake targeted outreach, both prior to and during the plan year, directly to Part D enrollees likely to benefit from the program.

To support Part D sponsors in meeting these requirements, CMS has developed a standardized notice for Part D enrollees identified as likely to benefit from the Medicare Prescription Payment Plan, the “Medicare Prescription Payment Plan Likely to Benefit Notice.” Part D sponsors are required to use this standardized notice to satisfy their obligation to perform targeted outreach to Part D enrollees who are identified as likely to benefit prior to and during the plan year, including those identified through the pharmacy notification process. This outreach, when performed outside of the pharmacy point of sale (POS) notification process, may be done via mail or electronically (based on the Part D enrollee’s preferred and authorized communication methods). If the enrollee is identified through the pharmacy notification process, this outreach must be completed at the pharmacy POS. Specific parameters around how and when Part D sponsors must use the “Medicare Prescription Payment Plan Likely to Benefit Notice” to meet the targeted outreach requirements are outlined in the Medicare Prescription Payment Plan part two guidance.

This is a standardized notice, the content of which may not be altered. The OMB control number must be displayed in the lower right corner of the notice.

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Logo not required when distributed by the pharmacy. When distributed by the Part D sponsor outside of the pharmacy POS process, Part D plans may elect to place their logo in the header. The name, address, and telephone number of the Part D plan must be immediately under the logo, if not incorporated within the logo.

Form CMS-XXXXX OMB Approval No. XXXX-XXXX (Expires: XX/XX/20XX)