How does the Part D "catastrophic coverage" phase work once I hit the out-of-pocket max?
Answered by 25 licensed agents
There is no Catastrophic phase anymore No donut hole
Answered by Tasha Riggs on April 1, 2025
Broker Licensed in CO, AZ, HI & 10 other states
Answered by Bill Wheeler on July 14, 2025
Broker Licensed in KY & IN
Answered by Luke Rhoads on July 11, 2025
Broker Licensed in OK
Answered by David Quintal on April 28, 2025
Broker Licensed in NH, AL, AZ & 14 other states
Just to be clear your prescriptions still have to be listed in the formulary (the list of drugs covered) by the Part D plan. It isn't that your doctor can write a prescription for whatever and it be covered at 100%.
All in all this new OOPMax is a very good thing for consumers.
Answered by Andrew Bennett on April 14, 2025
Broker Licensed in TN, GA & VA
Answered by Shane and Tammy Carpenter on March 23, 2025
Broker Licensed in OK, AR, FL & 5 other states
However, in 2025, the max out-of-pocket is capped at $2,000 for everyone. Once you have met that maximum amount, you will no longer have to pay for your covered prescriptions the rest of the year.
Answered by Diana Garner on June 23, 2025
Broker Licensed in KY, FL, IN, OH & TN
Answered by Timothy Brown on April 8, 2025
Broker Licensed in PA, CT, DE & 15 other states
Answered by Barbara Barnes, CMIP® on July 2, 2025
Agent Licensed in PA
Starting in 2025 once you hit the annual out of pocket max there will be no more catastrophic cost phase sharing.
The maximum (troop) limit for 2025 is $2,000 one you reached the $2,000 limit for out of pocket drugs, you pay nothing for your medications.
Answered by Janet Cruz on June 22, 2025
Broker Licensed in FL
Answered by Rene Casanova on April 14, 2025
Broker Licensed in TX
Answered by Heidi Delaney on July 30, 2025
Broker Licensed in CO, AZ, KS & 5 other states
Answered by Rachel Armstrong on May 27, 2025
Broker Licensed in GA, AL & FL
Here's a more detailed breakdown:
Out-of-Pocket Maximum:
You reach this point after accumulating $2,000 in out-of-pocket costs for covered drugs.
No Additional Costs:
After hitting the maximum, you don't pay any copays, coinsurance, or deductibles for covered drugs for the rest of the calendar year.
Coverage Simplification:
This phase eliminates the coverage gap (also known as the "donut hole"), which used to exist before 2025.
Ongoing Premium:
You still need to pay your monthly Part D premium, but you won't have any further out-of-pocket costs for covered drugs.
Answered by Fred Manas on May 7, 2025
Agent Licensed in NY, CT, DC & 7 other states
Answered by Vachik Chakhbazian on May 7, 2025
Agent Licensed in CA, AL, AR & 22 other states
This law started in January of 2025 and so far the current administration hasn't figured out how to revoke it and thank God
Answered by Gary Henderson on April 19, 2025
Agent Licensed in TX, AK, AL & 46 other states
Answered by Steve Brauer on April 8, 2025
Broker Licensed in AZ & CA
Once you cross the 2,000 max out-of-pocket thresholds, you incur no more cost for the rest of the year.
Answered by Deborah Webster on July 11, 2025
Broker Licensed in Ia & SC
Answered by Rodolfo Rojas on July 23, 2025
Broker Licensed in NV, AL, AR & 22 other states
Answered by Ingrid Kollmann on June 2, 2025
Agent Licensed in CA
Answered by Nicolas Johnson on May 28, 2025
Agent Licensed in WI & IA
Answered by Steven Rukhman on July 28, 2025
Broker Licensed in CA, AZ, NM, NV, OR & TX
1. **Out-of-Pocket Costs**: To reach the catastrophic coverage phase, you must have incurred a certain amount in out-of-pocket costs for covered prescription drugs. This includes your deductible, copayments, and coinsurance. The specific threshold can change annually, so checking the current limit for the year is important.
2. **Catastrophic Coverage**: After you reach the out-of-pocket maximum, your coverage shifts to catastrophic coverage. This means that your costs for covered medications will significantly reduce.
3. **Cost Sharing in Catastrophic Phase**:
- During the catastrophic coverage phase, you will generally pay a small copayment or coinsurance for each prescription. As of 2025, most beneficiaries will pay either $4.15 for generic drugs or $10.35 for brand-name drugs, or 5% of the drug cost, whichever is higher.
- The exact amount you pay can vary based on the specific Part D plan you are enrolled in.
4. **Coverage Continuity**: Catastrophic coverage continues for the remainder of the calendar year, where you will only pay the reduced coinsurance or copayment for your medications.
5. **Annual Reset**: At the beginning of the next calendar year, your out-of-pocket costs reset, and you will need to go through the phases of the Part D coverage again.
Understanding how catastrophic coverage works can help you plan for your medication expenses, especially if you have high prescription drug costs. If you have any further questions or need assistance with your Medicare options, feel free to reach out to us at Feliciano Fiduciary Services!
Answered by Angel Feliciano on July 28, 2025
Broker Licensed in NY, FL & OH
Answered by Michael Hixson on April 23, 2025
Broker Licensed in OK, AR & TX
That's right—$0 copays for all covered medications once you hit the cap!
Answered by Angela Wainright on July 25, 2025
Broker Licensed in MN, AZ & ND
Tags: Coverage Medicare Part D Prescription Drug
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