The following list contains the sequencing of captions and paragraphs for Income-Related Monthly Adjustment Amount (IRMAA) Annual Verification Determination Notices for T2 beneficiaries. An “R” indicates a required paragraph, while an “O” indicates an optional paragraph.

• •

  Introductory (no caption)

  MIR100 O

  Or MIR099 O

  MIR098 R

  MIR004 R

  MIR065 R

  MIR016 O

  MIR006 O

  MIR007 R

  MIR017 O

  MIR008 R

• •

  MIRC02 – Another Letter

  MIR011 O

  MIR012 O

• •

  MIRC04 – How We Decided Your Income-Related Premium Amount

  MIR111 O

  MIR113 R

  MIR112 R

  MIR119 R

  MIR020 R

  MIR114 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

  REF103 O

  REF104 O

  REF106 O

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

• •

  Introductory (no caption)

  MIR100 O

  Or MIR099 O

  MIR098 R

  MIR018 R

• •

  COPC01 – Other Information

  MIR013 O

  MIR122 O

  MIR123 O

  MIR124 O

• •

  MIRC04 – How We Decided Your Income-Related Premium Amount

  MIR111 O

  MIR113 R

  MIR112 R

  MIR019 R

  MIR020 R

  MIR114 O

• •

  ALSC19 – If You Disagree With This Decision

  ALS162 R

• •

  REPC01 – If You Want Help With Your Appeals

  REP031 R

• •

  REFC01 – If You Have Any Questions

  REF093 (RRB) O

  REF103 O

  REF104 O

  REF106 O