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?