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

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

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.

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.

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

Steve 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 Brauer on April 8, 2025

Broker Licensed in AZ & CA

Answered by Steve Brauer Medicare Insurance Agent

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.

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

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

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

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

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