Advertiser Disclosure

True Out of Pocket (TrOOP) Costs for Medicare: What to Know

5 mins read
Our goal is to give you the tools and confidence you need to improve your health and finances. Although we may receive compensation from our partner insurance companies, whom we will always identify, all opinions are our own. CoverRight Inc. and CoverRight Insurance Services Inc. (NPN: 19724057) are collectively referred to here as "CoverRight".

Navigating your healthcare expenses under Medicare can be challenging, especially when dealing with prescription drug costs under Medicare Part D. 

A key term you’ll frequently encounter is True Out-of-Pocket costs, or TrOOP. This figure is crucial in determining when you transition from standard coverage to catastrophic coverage, effectively capping your annual spending on prescription medications. 

In this article, we’ll break down the intricacies of TrOOP, explore what types of payments count toward it, and discuss its significance in moving you out of the Medicare Part D coverage gap—commonly called the “donut hole.” With the TrOOP threshold set at $7,400 for 2023, it’s essential to grasp how this number impacts your healthcare expenses for the year.

TrOOP Medicare: Navigating True Out-of-Pocket Costs

TrOOP is a pivotal element in your Medicare Part D prescription drug plan. It designates the maximum sum you must spend out-of-pocket on prescription drugs within a plan year before shifting to catastrophic drug coverage.

The Centers for Medicare & Medicaid Services (CMS) has set the TrOOP threshold at $7,400 for 2023. Once you reach this cap, you enter the catastrophic coverage level, where your out-of-pocket spending on covered drugs significantly reduces for the remainder of the year.

Reaching the TrOOP limit offers a welcome relief, especially for those on multiple or high-cost medications. Hitting this threshold reduces your costs to minor coinsurance or copayments for the rest of the year. This makes tracking your TrOOP vital for effective healthcare budgeting and maximizing Medicare Part D benefits.

What Payments Count Toward TrOOP?

Understanding what types of payments contribute to your TrOOP costs can be invaluable for managing your healthcare budget. Here is a breakdown of the payments that count:

  1. Annual deductible: If your plan has a yearly deductible, you must meet this financial obligation before your Medicare Part D drug plan kicks in to cover your medication expenses. This deductible amount is counted toward your TrOOP.
  2. Coinsurance and copayments: Once your plan starts covering your medications, you’re typically responsible for either a coinsurance or copayment for each prescription you fill. These out-of-pocket expenses also contribute to your TrOOP.
  3. Coverage gap expenses: If your plan has a coverage gap, or “donut hole,” payments made for covered drugs during this phase also count toward your TrOOP.
  4. Discount on brand-name drugs: You can also receive a 70% discount on your plan’s brand-name drugs if you’re in the coverage gap. Although you’re only responsible for 25% of the drug’s listed prices, nearly the entire cost is counted toward your TrOOP. This helps you move out of the coverage gap more swiftly. While your Medicare Part D plan covers an additional 5% of the drug’s cost, this portion does not count toward your TrOOP.

Now that we’ve covered what types of payments contribute to your TrOOP, let’s look at who is eligible to make these payments on your behalf or as direct contributions:

  • The individual enrolled in the Medicare Part D plan (including payments from MSA, HSA, or FSA accounts)
  • Friends or family members
  • Qualified State Pharmacy Assistance Programs (SPAPs)
  • Medicare’s Extra Help 
  • Most charitable organizations not affiliated with the enrollee’s employer, union, or drug manufacturer.

Special Cases

Payments also count if they’re made by the Indian Health Service, AIDS Drug Assistance Programs (ADAPs), or drug manufacturers providing discounts under the Medicare coverage gap discount program.

What Qualifies the Drugs?

Only payments for drugs that meet the following conditions count toward TrOOP:

  • The drugs are mentioned in your plan’s formulary, or are treated as such due to an exceptions process.
  • The drugs are bought at a network pharmacy or comply with the plan’s out-of-network policy.

What Costs Aren’t Counted Toward TrOOP?

Understanding which payments do not qualify toward your TrOOP costs is just as crucial. Here’s what does not contribute:

  1. Share paid by the plan: Any portion of the drug cost covered by your Medicare Part D plan will not count toward your TrOOP. This includes 5% of the drug’s cost and 75% of the dispensing fee paid by Medicare during the coverage gap phase.
  2. Monthly premiums: The monthly premium for your Medicare Part D prescription drug plan does not count toward your TrOOP.
  3. Non-formulary drugs: If you buy drugs not covered by your plan’s formulary and have not been approved through an exceptions process, these costs will not count toward your TrOOP.
  4. Excluded drugs: Even if your plan covers them as a supplemental benefit, drugs excluded from the definition of a Part D drug, such as medications for hair growth, will not count.
  5. Over-the-Counter Medications and Vitamins: Costs for most over-the-counter drugs, even if required as part of a step therapy program, do not contribute to your TrOOP.

Third-Party Payments:

Payments for your drugs don’t count toward your TrOOP if they’re made by or reimbursed to you by:

  • Employer or union plans: Programs like Federal Employees Health Benefits (FEHB).
  • Government programs: This includes Medicaid, TRICARE, Workers’ Compensation, the Department of Veterans Affairs (VA), and other federally funded programs like FQHCs, RHCs, CHIP, and black lung benefits.
  • Other third-party obligations: Organizations legally required to pay for your drug costs, like certain insurance plans, also do not count toward your TrOOP.
  • Patient assistance programs: Payments from Patient Assistance Programs (PAPs) outside the Part D benefits are also not counted toward your TrOOP.

If you have coverage from these third parties paying part of your out-of-pocket costs, you must inform your Medicare Part D plan, as these will not count toward reaching your TrOOP threshold.

Understanding the Coverage Gap or ‘Donut Hole’

The Medicare Part D “Donut Hole,” also known as the Coverage Gap, is a phase where you shoulder a higher percentage of your prescription drug costs. You enter this phase after your total drug spending reaches an initial coverage limit of $4,660 (2023).

You typically pay 25% of your medication costs during the Coverage Gap, similar to the initial coverage phase. Your True Out-of-Pocket costs (TrOOP) are crucial here, as they determine how long you remain in this phase. Once your TrOOP reaches $7,400 (2023), you move to the Catastrophic Coverage stage, where your costs drop significantly.

Since 2020, legislative adjustments have reduced the beneficiary’s financial burden in the Coverage Gap. Previously, you were responsible for a higher percentage of drug costs. Now, due to manufacturer discounts and federal subsidies, your share is generally only 25%. Your TrOOP now also includes manufacturer discounts on brand-name drugs, making it faster for you to move out of the Coverage Gap. This inclusion effectively lowers your overall financial responsibility while in this phase.

Need more information about True Out-of-Pocket costs under Medicare? CoverRight is here to guide you every step of the way.

We’re your trusted partner for customized Medicare solutions, from understanding the Coverage Gap to calculating your TrOOP expenses.

Connect with us today for personalized assistance and ensure you’re making the most informed decisions about your healthcare.

Frequently Asked Questions

What does TrOOP mean in the context of Medicare Part D?

TrOOP stands for “True Out-of-Pocket” costs. These expenses, which you personally have to cover, include your deductible, copayments, and coinsurance. In the Medicare Part D program context, reaching a certain TrOOP amount ($7,400 in 2023) triggers a transition from the Coverage Gap phase to the Catastrophic Coverage phase, substantially reducing your medication costs.

How does Medicare catastrophic coverage work?

After your TrOOP reaches the set limit, in this case, $7,400 in 2023, you enter the Catastrophic Coverage phase. In this phase, your out-of-pocket costs for prescription medications are drastically reduced. You would typically pay a nominal copay or a small percentage of the drug’s cost.

When can I change my Medicare drug plan, and is TrOOP affected?

You can change your Medicare drug plan during the Annual Election Period (AEP), which runs from October 15 to December 7. If you switch your plan during the year, your TrOOP balance transfers to your new Medicare drug plan. Medicare has established processes to ensure this transfer is smooth, starting when you disenroll from your current plan and enroll in a new one. Your TrOOP costs effectively carry over, helping you progress toward reaching the thresholds for the Coverage Gap and Catastrophic Coverage in your new plan.

How does Extra Help affect entering the coverage gap?

If you qualify for Extra Help, a federal program designed to aid those with limited income and resources, you won’t enter the Coverage Gap, also known as the “Donut Hole.” Extra Help assists with various Part D costs, including deductibles and copays, thus effectively keeping you out of the gap phase or significantly lowering your costs if you enter it. You can apply for Extra Help anytime, before or after enrolling in a Medicare Part D plan.

Richard Chan

Richard is the Founder of CoverRight and based in New York. He is passionate about empowering consumers to take control of their health and finances. Prior to starting CoverRight, Richard had extensive experience working in financial services with over 8 years' experience in consumer lending and investment banking.

Latest from Blog