The following list contains the sequencing of captions and paragraphs for IRMAA Initial Determination Notices for T2 beneficiaries. An “R” indicates a required paragraph, while an “O” indicates an optional paragraph.

• •

  Introductory (no caption)

  MIR003                       R

  MIR004                       R

  MIR065                       R

  MIR016                       O

  MIR006                       O

  MIR007                       R

  MIR017                       O

  MIR008                       R

• •

  MIRC02 – Another Letter

  MIR010                       R

• •

  MIRC04 – How We Decided Your Income-Related Premium Amount

  MIR080                       O

  MIR081                       O

  MIR084                       O

  MIR030                       O

  MIR019                       R

  MIR020                       R

  MIR097                       O

• •

  MIRC03 – If You Have Other Information About Your Income

  MIR021                      O

  MIR027                      O

  MIR022                      R

  MIR026                      O

  MIR023                      O

  MIR024                      R

  MIR088                      R

  MIR025                      O

• •

  ALSC19 – If You Disagree With This Decision

  ALS162                      R

• •

  REPC01 – If You Want Help With Your Appeal

  REPO31                     R

• •

  REFC01 – If You Have Any Questions

  REF103                     O

  REF104                     O

  REF106                     O

The following list contains the sequencing of captions and paragraphs for IRMAA Initial Determination Notices for Non-T2 beneficiaries. An “R” indicates a required paragraph, while an “O” indicates an optional paragraph.

• •

  Introductory (no caption)

  MIR003                     R

  MIR018                     R

• •

  COPC01 – Other Information

  MIR013                     O

• •

  · MIRC04 – How We Decided Your Income-Related Premium Amount

  MIR080                    O

  MIR081                    O

  MIR084                     O

  MIR030                     O

  MIR019                     R

  MIR020                     R

  MIR097                     O

• •

  MIRC03 – If You Have Other Information About Your Income

  MIR021                     O

  MIR027                     O

  MIR022                     R

  MIR026                     O

  MIR023                     O

  MIR024                     R

  MIR088                     R

  MIR025                     O

• •

  ALSC19 – If You Disagree With This Decision

  ALS162                     R

• •

  REPC01 – If You Want Help With Your Appeal

  REP031                     R

• •

  REFC01 - If You Have Any Questions

  REF093                     O

  REF103                     O

  REF104                     O

  REF106                     O