2025 Standard Drug Coverage Question

[Crisfig]

Hi!

I have found contradictory information about whether or not a person will have to pay their prescription drug deductible in a new plan they switch to if they already paid it in a previous plan; Or if the coinsurance or copayments the person paid during the initial coverage period in his or her former plan and what the plan paid will all count toward the new deductible in the new plan?


Thank you!

 

[somarco]

If you use a Special Enrollment Period (SEP) to change Medicare plans during the year, you will find that both the total retail value of your drug purchases (gross covered drug costs*) and the total value of your out-of-pocket spending (TrOOP) transfer to your new Medicare Part D drug plan.

So, if you change Medicare plans mid-year, the money you spent in your initial deductible (total out-of-pocket spending or TrOOP) in your first Part D plan, transfers with you to your new Medicare Part D plan.

Important: You may have a new Medicare plan - but, you may not be in the same phase of coverage as before.

Depending on the structure (deductible or no deductible) and coverage limits of your new Medicare drug plan as compared to your old plan, you may not be in the same phase of coverage when you change plans during the year.

If I change my Medicare prescription drug plan during the year, will my drug deductible transfer to the new Part D plan?

Yes. If you use a Special Enrollment Period (SEP) to change Medicare drug plans during the year, you will find that both the total retail value of your drug purchases and the total value of your out-of-pocket spending (TrOOP) transfer to your new Part D plan.

q1medicare.com

 

[Crisfig]

Thank you for the information. The examples given are going from a $0 deductible plan to one with a deductible. What about going from a MAPD plan with a drug deductible, which they have satisfied already, to a new plan that has a drug deductible? Would what they have spent in the previous plan count towards covering the new plan's drug deductible?

 

[Rossat]

Thank you for the information. The examples given are going from a $0 deductible plan to one with a deductible. What about going from a MAPD plan with a drug deductible, which they have satisfied already, to a new plan that has a drug deductible? Would what they have spent in the previous plan count towards covering the new plan's drug deductible?

The TrOOP carries over.

If you had a deductible of $200, then a copay of $50 after the deductible, and the drug retailed at $300: TrOOP = $200 (deductible) + $50 copay = $250.

The $250 would carry over to the new plan. The $50 ($250+$50= $300) paid for by the insurance company would not.

 

[Rossat]

A piece of advice...

Personally, I'm not getting this far into the weeds with them. I'll know the structure of the current/past plan, but I'd have no way of knowing what phase they are in, how much they spent, and I'm damn not taking their word on it. Its setting up for failure or "you told me I'd pay X"

The TrOOP is calculated and kept by Medicare, not the carriers. So I make the statements such as "I'm quoting based on the remainder of the year as though you were just starting this plan. Any payments you may have made for medications under the old plan will be considered, and you may not spend this amount."

 

[straightnochaser]

The simplest way to explain this is TrOOP is set by CMS and is static whereas the deductibles are set by the plan

You would never start a troop over as that would be against CMS regs but if you have a plan with no deductible, and you move someone to a plan with a deductible and the 2k cap has not yet been met then yes the deductible will need to be paid

 

[kgmom219]

1. I am assuming you are talking about an OEP move for MAPD.
2. Medical Accummulators do not move with the client
3. Pharmacy Accumulators DO move with the client. (Except it never works and takes 90 days)