Deep Cuts: TrOOP & Cost Rules
What must drugs typically be for costs to count toward TrOOP?
On the formulary and purchased at a network pharmacy
What is a formulary?
A list of drugs a Part D plan covers
What are “preferred pharmacies”?
Pharmacies with lower cost-sharing than others in-network.
What is one way to pay a Part D premium?
Bank draft, billing, or Social Security deduction.
Which country has won the most FIFA World Cups?
Brazil
After reaching the catastrophic phase in 2025, how much does the enrollee pay?
$0
Name one type of drug excluded from Part D coverage.
Weight loss drugs, vitamins (most), cosmetic drugs, OTC drugs, etc.
What is step therapy?
Trying lower-cost drugs before more expensive ones.
Can prescription drug plans deny someone based on health status?
No
How often is the World Cup held?
Every 4 years
What is the 2026 out-of-pocket cap before catastrophic coverage begins?
$2100
Name two types of items covered under Part D.
Prescription drugs, biologics, insulin, vaccines.
What is “tiering”?
Grouping drugs into cost levels (tiers) with different pricing.
Part D LEP - What is it? How is it calculated?
63+ days w/out Part D
Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” (also called the “base beneficiary premium”) by the number of full, uncovered months the person didn’t have Part D or creditable coverage. The monthly penalty is rounded to the nearest $.10 and added to their monthly Part D premium.
Who won the 2022 FIFA World Cup?
Argentina
Name two types of payment that does NOT count toward TrOOP.
Examples: OTC drugs, out-of-network purchases, Medicaid payments, or non-formulary drugs.
How many drugs must generally be included in each therapeutic category?
At least two
What are two types of plans that include Part D coverage?
PDPs and MA-PD plans (also Cost-PD, PACE, etc.).
Who provides Part D coverage?
Private companies.
What year was the first FIFA World Cup?
1930
What does “TrOOP” stand for and what does it determine?
True Out-of-Pocket costs; it determines when a beneficiary reaches catastrophic coverage.
When are erectile dysfunction drugs excluded from Part D?
When used for sexual dysfunction
What must be true for a plan to qualify as “actuarially equivalent” alternative coverage?
It must provide benefits at least equal in value to standard coverage
What must someone have to be eligible for Part D?
Part A and/or Part B.
What is the best finish the U.S. Men’s National Team has ever achieved in a World Cup?
Third place (1930)