“Agents and consumers do not need to know how to calculate the costs…” Really?
It’s October 1 and 2025 Medicare plans are out. What the heck is going on with Medicare Plan Finder and the $2,000 MOOP for drugs in 2025?!
I went into Medicare’s Plan Finder first thing this morning and entered two expensive brand name medications: Eliquis and Ozempic. I was shocked to find MAPD plans getting into catastrophic coverage after the member pays only $360. How is that possible?!
That lead me on a long journey including a ton of reading on Medicare.gov and CMS.gov, an argument with ChatGPT, a discussion with Google Gemini (both were wrong by the way), and eventually FAQ documents on carrier websites.
What I found is that Medicare.gov and CMS.gov have poor explanations of how the Max out-of-pocket actually works. Also, the implementation guides from CMS (one that I skimmed was almost 800 pages long) are very vague and don’t spell it out clearly.
Eventually, I found FAQ documents from several carriers that explain in plain english what is really going on:
“The amount that is applied towards a members’ TrOOP is the greater of the amount paid by a member based on their Plan’s benefit design OR the cost share that the member would have under Medicare’s Defined Standard Part D Plan.”
Why don’t Medicare and CMS explain this in their documents and websites?
FYI, stand-alone Prescription Drug Plans for 2025 look similar to the standard benefit design and in most cases had the member paying $2,000 before getting to catastrophic coverage.
