How does the Part D "catastrophic coverage" phase work once I hit the out-of-pocket max?

Question

Tasha Riggs · Accepted Answer

Once you hit the 2,000 max out of pocket everything is Covered 100% 
There is no Catastrophic phase anymore No donut hole

Steve and Sue Brauer · Answer

Every Part D Prescription Drug Plan, whether its a stand alone plan, or attached to a Medicare Advantage Plan has a list of Formulary Drugs.... the prescription drugs they're willing to cover on your plan. You enter the Catastrophic Coverage phase once you've reached the $2000 limit, a formula between what YOU'VE paid on prescriptions and the cost of those prescriptions from the drug company. All your FORMULARY drugs are covered at no charge for the rest of the calendar year.

Answered by Steve and Sue Brauer on April 8, 2025

Broker Licensed in AZ & CA

Answered by Steve and Sue Brauer Medicare Insurance Agent

Bill Wheeler · Answer

Now starting in 2025 Medicare  part d is $2000.00. Once you reach  coverage your out of pocket  is zero for the rest of the year.

Luke Rhoads · Answer

Once you reach $2000 out of pocket for the year you have $0 co-pays for the remainder of the calendar year for your prescription drug costs.

David Quintal · Answer

Based on the 2025 changes, once an individual hits the out-of-pocket max they pay nothing for the rest of the calendar year. The out-of-pocket max is $2000 for 2025. Once you hit $2000 you enter the "catastrophic phase" and pay nothing more than $2000 for covered medications.

Answered by David Quintal on April 28, 2025

Broker Licensed in NH, AL, AZ & 14 other states

Answered by David Quintal Medicare Insurance Agent

Andrew Bennett · Answer

Once you hit the out-of-pocket maximum you no longer pay anything for your covered prescriptions.  The OOPMax is now $2000.  The interesting thing is that it could be less than that as some of the discounts between the insurance company and the pharmaceutical company are counted into that $2000.  

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.

Shane and Tammy Carpenter · Answer

If you have met the "catastrophic coverage" phase, you will have no further responsibility towards drugs covered in your plan's formulary. However, if you are on medications not covered by your Part D prescription drug plan, you will still be responsible to pay those costs.

Answered by Shane and Tammy Carpenter on March 23, 2025

Broker Licensed in OK, AR, FL & 5 other states

Answered by Shane and Tammy Carpenter Medicare Insurance Agent

Wade Lashley · Answer

Once you reach the catastrophic phase you won't pay anything for your Medicare covered part D drugs.

Diana Garner · Answer

Once you have met your max out-of-pocket, the "catastrophic coverage" phase begins. During this phase, you pay very little or nothing for your prescription drugs for the rest of the year.

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.

Timothy Brown · Answer

Once the $2,000 out-of-pocket max is hit, the cost /copay for all prescriptions will be $0 for the remainder of 2025.

Barbara Barnes, CMIP® · Answer

Once you hit the out-of-pocket maximum, you will pay $0 for covered medications for the rest of the plan year. Please note that this only applies to ‘covered’ medications. If you get a medication that is not covered by the plan, for whatever reason, you will be required to pay for that medication, even if you’ve met the out-of-pocket maximum.

Answered by Barbara Barnes, CMIP® on July 2, 2025

Agent Licensed in PA

Answered by Barbara Barnes, CMIP® Medicare Insurance Agent

Heidi Delaney · Answer

Once you hit the catastrophic phase, the medications that are on the plan formulary, including any your physician got added for you will cost you $0.

Janet Cruz · Answer

The catastrophic coverage phase worked this way, in previous years you would have to pay 5% of the cost of each drug or a small copay whichever is greater. After you reached the catastrophic ( troop). The plan and Medicare pays the rest. 

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.

Rachel Armstrong · Answer

Once you hit the $2000 max out of pocket, your prescription medication will be free of charge for the  remainder of the year.

Fred Manas · Answer

In the catastrophic coverage phase of Medicare Part D, you pay $0 for covered prescription drugs for the rest of the year after you've reached the out-of-pocket maximum. This maximum is $2,000 in 2025. Once you've reached this limit, the plan covers 100% of the cost of your covered drugs. 
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.

Vachik Chakhbazian · Answer

In 2025, once your out-of-pocket prescription drug costs reach $2,000, you enter the catastrophic coverage phase of Medicare Part D. At this point, you won't have to pay anything for covered Part D drugs for the rest of the year

Answered by Vachik Chakhbazian on May 7, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Gary Henderson · Answer

Once you hit the $2,000 out-of-pocket Max, your drugs are no cost to you for the rest of the year 
This law started in January of 2025 and so far the current administration hasn't figured out how to revoke it and thank God

Deborah Webster · Answer

Your medication costs go to 0 regardless of the tier of medication you are taking.
Once you cross the 2,000 max out-of-pocket thresholds, you incur no more cost for the rest of the year.

Rodolfo Rojas · Answer

After you get to catastrophic phase, you don't pay for medications that are included in the formulary.

Ingrid Kollmann · Answer

Once you reach the out-of-pocket maximum (e.g., $2,000 in 2025), you'll enter the catastrophic coverage phase, you won't have to pay anything out-of-pocket for your covered Part D drugs for the rest of the calendar year.

Answered by Ingrid Kollmann on June 2, 2025

Agent Licensed in CA

Answered by Ingrid Kollmann Medicare Insurance Agent

Nicolas Johnson · Answer

Once you exceed $2000 in out of pocket prescription drug costs, you no longer pay a coinsurance for the remainder of the year

Angela Wainright · Answer

Once your out-of-pocket drug costs reach $2,000 for the year (in 2025) (this includes deductibles, copays, coinsurance, and what you’ve paid for medications), you’ll pay nothing for your covered prescriptions for the rest of the year.

That's right—$0 copays for all covered medications once you hit the cap!

Steven Rukhman · Answer

With recently implemented Part D Redesign, in the Catastrophic Coverage Phase (Phase 3), all plan-covered Part D medications are paid 100% by the Part D plan for the remainder of the year.

Rene Casanova · Answer

Once any of us on Medicare with a Part D prescription drug plan (PDP) pay out of our pocket $2,000 in any calendar year you are done and all medications thereafter this limit are covered at 100%. This limit includes the $590 calendar year deductible when you have to pay it.

Answered by Rene Casanova on April 14, 2025

Broker Licensed in TX

Answered by Rene Casanova Medicare Insurance Agent

Michael Hixson · Answer

For year 2025 Part D has had a great change. In previous years when you entered into the Catastrophic Stage of your Drug Plan, you would have a copay that was determined by if it was a generic or name brand drug. You would pay the higher of the defined copay or 5% of the cost of the drug. For 2025 you no longer have a copay in the catastrophic stage, meaning that you will have a maximum of $2,000 drug cost for the year. Some may pay less than that depending on how CMS calculates and credits the copays that you paid.

Answered by Michael Hixson on April 23, 2025

Broker Licensed in OK, AR & TX

Answered by Michael Hixson Medicare Insurance Agent

Angel Feliciano · Answer

Once you reach the out-of-pocket maximum in the Medicare Part D prescription drug plan, you enter the "catastrophic coverage" phase. Here’s how it works:

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!

Craig Livers · Answer

Due to Inflation Reduction Act, you out-of-pocket maximum expense for prescription medications in 2025 is capped at $2000. In 2026, your maximum out-of-pocket expense will be $2100.

How does the Part D "catastrophic coverage" phase work once I hit the out-of-pocket max?

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How does the Part D "catastrophic coverage" phase work once I hit the out-of-pocket max?

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