True Out-of-Pocket (TrOOP) costs can feel like a confusing maze. But here’s a key point:
👉 If you switch Medicare Part D plans, your TrOOP amount goes with you.
That’s right—whether you’re moving to a new plan mid-year or during Open Enrollment, you don’t lose credit for what you’ve already spent.
What Counts Toward Your TrOOP?
Your TrOOP includes what you pay out of pocket toward prescription drugs, plus a few others who can contribute on your behalf, such as:
- You – Your copays, coinsurance, and deductible payments.
- Extra Help (LIS) – Subsidies from this federal program count.
- State Pharmacy Assistance Programs (like PACE/PACENET) – Their contributions also help you progress toward catastrophic coverage.
- Family Members or Charities – If someone helps pay for your medications (not an insurance company), that counts too.
What Doesn’t Count?
❌ Any payments made by your Part D plan
❌ Manufacturer discounts from the Deductible stage (more on that below)
❌ Payments from other insurance (like TriCare, VA, or employer coverage)
What’s New and Why It Matters
With the rollout of recent updates like the Inflation Reduction Act, and new rules on tier exemptions (which sometimes exclude drugs from the deductible), tracking TrOOP is trickier than ever.
Here’s what to watch for:
🧾 Tier Exemptions: Some medications, such as select generics or insulins, may not apply toward your deductible, which can slow your progress toward TrOOP unless you’re actively filling other prescriptions.
💸 $35 Insulin Cap: While great news for your wallet, the capped cost can affect how fast you move through the Part D phases.
Pro Tip: Don’t Guess—Check Your TrOOP Progress
Most Part D plans offer an online portal or mobile app where you can track your TrOOP. If you switch plans, confirm your updated TrOOP balance with your new plan to avoid any surprises at the pharmacy counter.
Bottom Line
Even though plans can change, your progress toward catastrophic drug coverage doesn’t reset. That’s why it’s important to stay informed—and to make sure you or your clients understand what counts, what doesn’t, and how recent changes may impact that journey.
Have questions about tier exemptions or tracking TrOOP in your current plan? Let’s talk.
📞 Have any questions?
Contact National Insurance Markets today and get expert support from agents who put clients first.
