How is the $2000 MOOP calculated?

[MBSC]

I was under the impression the $2k was member responsibility hence everyone talking about $160 a month

The $2000 cap is on the TrOOP according to the chart on page 4 of this document. The example uses a copay, so the person's actual OOP is less. The column on the far right is their monthly payment.

https://www.cms.gov/files/document/hpms-medicare-prescription-payment-plan-troop-memorandum.pdf

 

[Jim Wright]

Incorrect . There’s other reimbursements from the carriers and drug company rebates going toward the $2k. I’ve read 4 times the avg person will spend $1200 to get to the $2k moop. I don’t believe there’s an accuarate wa for an agent to fig this out

There is an easy way. The Troop Calculation is based off the standard plan even if you have enhanced benefit. Example:

Ozempic is $1000 retail. On standard plan, they would pay the $590 deductible and then 25% coinsurance = 692.50 for the first month. Second month, they pay $250, etc until they reach $2000 Moop and they are done. Standard plan is dollars to dollars.

If enhanced, they pay $255 deductible and $47 copay = $302. The first month counts as $692.50 towards the Moop even though they only paid $302. Next month, the $47 copay counts as $250 towards the Moop.

There may be some other rebates in there separately but when you are explaining to your clients, this is the way to explain it.

 

[DonP]

There is an easy way. The Troop Calculation is based off the standard plan even if you have enhanced benefit. Example:

Ozempic is $1000 retail. On standard plan, they would pay the $590 deductible and then 25% coinsurance = 692.50 for the first month. Second month, they pay $250, etc until they reach $2000 Moop and they are done. Standard plan is dollars to dollars.

If enhanced, they pay $255 deductible and $47 copay = $302. The first month counts as $692.50 towards the Moop even though they only paid $302. Next month, the $47 copay counts as $250 towards the Moop.

There may be some other rebates in there separately but when you are explaining to your clients, this is the way to explain it.

So what determines if a mapd rx part is enchanced or standard? Is enchanced if you have $ copays and standard if you have % copays ? The enchanced example your using is a $255 deductible plan?

 

[Jim Wright]

So what determines if a mapd rx part is enchanced or standard? Is enchanced if you have $ copays and standard if you have % copays ? The enchanced example your using is a $255 deductible plan?

That's what I can't get a straight answer on yet. I can make assumptions but that wouldn't be helpful.

 

[Fisher]

There is an easy way. The Troop Calculation is based off the standard plan even if you have enhanced benefit. Example:

Ozempic is $1000 retail. On standard plan, they would pay the $590 deductible and then 25% coinsurance = 692.50 for the first month. Second month, they pay $250, etc until they reach $2000 Moop and they are done. Standard plan is dollars to dollars.

If enhanced, they pay $255 deductible and $47 copay = $302. The first month counts as $692.50 towards the Moop even though they only paid $302. Next month, the $47 copay counts as $250 towards the Moop.

There may be some other rebates in there separately but when you are explaining to your clients, this is the way to explain it.

Not a chance.

Ms. Betty, it's government magic wand stuff. But no matter what, you won't pay more than $2000 out of your own pocket. Any questions?

 

[straightnochaser]

There is an easy way. The Troop Calculation is based off the standard plan even if you have enhanced benefit. Example:

Ozempic is $1000 retail. On standard plan, they would pay the $590 deductible and then 25% coinsurance = 692.50 for the first month. Second month, they pay $250, etc until they reach $2000 Moop and they are done. Standard plan is dollars to dollars.

If enhanced, they pay $255 deductible and $47 copay = $302. The first month counts as $692.50 towards the Moop even though they only paid $302. Next month, the $47 copay counts as $250 towards the Moop.

There may be some other rebates in there separately but when you are explaining to your clients, this is the way to explain it.

*most* Seniors aren't gonna understand this..

 

[kak6407]

Who's not getting paid, dude this is a bigger deal on mapd than pdp, and if your thinking your Wellcare members will stick with them hold on the anoc just hit and I got 3 calls today from pissed off people, guess what meds not covered on the slimmed down formulary let the fun begin

What meds aren't being covered on the VS? Inquiring minds want to know?

 

[Chazm]

*most* Seniors aren't gonna understand this..

Shoot, I don’t. But I’ve had some beers

 

[Millwood]

I'm more curious to find out if people taking 4 or 5 $1000+ drugs will even be able to a formulary that covers them all. Bet that gets fun.

 

[InsuranceGuy29]

Incorrect . There’s other reimbursements from the carriers and drug company rebates going toward the $2k. I’ve read 4 times the avg person will spend $1200 to get to the $2k moop. I don’t believe there’s an accuarate wa for an agent to fig this out

In one year, we went from a $8,000 catastrophic bracket with no MOOP, to a $2,000 hard MOOP cutoff where the average person will spend only $1,200.

Granted, SOME (<----key word) people definitely needed help with prescriptions, but that is such a HUGE change in such a short amount of time.

And the problem is, all this is doing is taking tons of extra other benefits away from the bulk of seniors, while simultaneously raising all of their monthly premiums, deductibles, and copays on their medical plans.

So yea, it's great for someone taking a ton of high-priced prescriptions, but that is not the majority of people on Medicare. Not even close.

So basically, the majority of people suffer for the minority of people. It's just not good policy, and the implementation was WAY too quick.

It also serves as no actual deterrent for people to actually try to get healthier, get better, and get off of these RX's.

Granted, I know some RX's are necessary for living....no doubt. But most are not, and they are very poisonous and carry with them a million other side effects. No one should be striving to take a lot of prescriptions as their "healthcare."

Natural supplements and vitamins should always be utilized and explored.

Unless someone is a diabetic or just had an organ transplant and needs to take rejections drugs.....something along those lines, people should be striving to find healthier ways to deal with things than many of these RX's.

And most of these super high-priced ones are just rackets of the pharmaceutical companies that are pushed HEAVILY by them to doctors, and in turn, the doctors push them HEAVILY to patients. All because of the super high profits. It' a giant racket.