 |
|
|
|
Questions & Answers (FAQ)
The categories of Frequently Asked Questions (FAQs) can be found to the right. Simply click on one of the questions below or a category to the right.
| What exactly is TrOOP or True Out of Pocket costs? |
|
|
The Centers for Medicare and Medicaid Services (CMS) explain that,
"True out-of-pocket (TrOOP) costs are the expenses that count toward a person’s Medicare drug plan out-of-pocket threshold (for example $4,550 in 2011). TrOOP costs determine when a person’s catastrophic coverage portion of their Medicare Part D prescription drug plan will begin."
In other words, TrOOP defines when you exit the Doughnut Hole or Coverage Gap and enter into the Catastrophic Coverage stage of your Medicare Part D prescription drug plan.
CMS also provides the following:
What payments count toward TrOOP costs?
The following payments count toward a person’s TrOOP costs:
• The amount a person pays for each Medicare Part D covered prescriptions before their Medicare Part D drug plan begins to pay (that is, your annual deductible, if applicable) - Most Medicare Part D plans do not have an initial deductible and begin with coverage from the first day. If you have a $310 initial deductible in your Medicare Part D plan, you pay 100% of the first $310 dollars and then your Medicare Part D plan begins to pay along with your co-insurance or co-payment. In this example, you get $310 credit toward your TrOOP.
• The amount a person pays for each Medicare Part D plan covered prescription drug after their drug plan begins to pay (that is, your co-payments or coinsurance). So if you have a $30 co-payment for a particular medication that is covered by your Part D prescription drug plan, you get TrOOP credit for the $30. If someone else, like a friend or family member, makes the payment for you (say, $30 in this example), then this amount is also counted toward TrOOP.
• Any payments a person makes during their plan’s coverage gap, if the plan has a coverage gap
• Any payments for drugs made by any of the following programs or organizations:
-- "Extra-Help" from Medicare
-- Medicare's Coverage Gap Discount Program (in 2011: 50% brand name drug discount, 7% Generic drug discount)
-- Indian Health Services
-- AIDS Drug Assistance Programs
-- Most Charities
-- State Pharmaceutical Assistance Programs (SPAPs)
For example, if you purchase a formulary or covered brand-name Medicare Part medication in the 2011 Coverage Gap or Donut Hole that has a negotiated retail cost of $100, you will pay $50 (or 50%) and $50 (or 50%) will be paid by the Discount Program. However, you will receive $100 (or 100%) credit toward your TrOOP
• Any money a person uses from their medical savings account on their Medicare Prescription Drug Plan deductibles or cost sharing, if the person has a Medicare Medical Savings Account (MSA) Plan and a Medicare Prescription Drug Plan
Payments only count toward TrOOP costs for drugs that meet these conditions:
• Are on the plan’s formulary
• Weren’t on the formulary, but were allowed to count toward true out-of-pocket costs because of a coverage determination, formulary exceptions process, or an appeal
• Were purchased in a network pharmacy
• Were purchased at an out-of-network pharmacy in accordance with the plan’s out-of-network policy
Again, payments count toward a person’s TrOOP costs if they are made by any of the following:
• The person is with Medicare
• Family members or friends
• Qualified State Pharmacy Assistance Programs (SPAPs)
• Medicare’s extra help (low-income subsidy)
• Medicare’s Coverage Gap Discount Program
• Most charities (unless they are established, run, or controlled by the person’s current or
former employer or union)
What payments DON’T count toward TrOOP costs?
Payments for the following don’t count toward a person’s TrOOP costs
:•Monthly premium
•Drugs purchased outside the United States and its territories
•Drugs not covered on the Medicare Part D plan formulary or drug list
•Drugs covered by the plan that are excluded by Medicare law (drugs such as benzodiazepines will become part of the Medicare Part D program in 2013 - as per Section 175 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that removes the exclusion of Barbiturates and Benzodiazepines from Medicare Part D plans - effective January 1, 2013. )
•Over-the-counter drugs or vitamins (even if they are required by the plan as part of step therapy)
|
|
|
|
|
|
|
|
|
|
|
| |
Life Insurance plays an important role in your families financial stability.
| |
|
|
Enroll 2010
