When $2100 is not what it appears. The Medicare Part D trap

Medicare Part D now limits the patient’s out of pocket costs to $2,100 a year (2026) adjusted each year.

There are conditions. Your Plan D is responsible for tracking your spending. 

Every time you fill a covered prescription:

• The pharmacy submits the claim electronically to your Part D plan
• The plan records: what the drug costs, what you paid, what the plan paid
• Once you hit the limit, you pay $0 for covered drugs for the rest of the year. You don’t apply, report, or file anything. It’s automatic and nationwide. 

However, if a drug is not covered by your plan, it usually does NOT count toward the cap. You could appeal for an exception.

A Non-formulary drug (not on your plan’s list) does not count. If you pay cash, it does not count toward the cap. If you use a discount card like GoodRx to save money, it does not count. 

Recently one of my wife’s doctors gave her samples of a drug. It worked quickly and effectively. When we got the prescription we found it was not covered by her Part D plan. It would be out of pocket at $500 a month using GoodRx. And of course, I now know it won’t count toward the $2100 out of pocket maximum. So with a Plan D and a $2100 annual cap, we still face a bill of $6,000 a year. 

What a system we have. Part D plans are not uniform in the drugs they cover and we are expected to select a plan not knowing what future prescriptions may or may not be covered. The lack of uniformity and abundance of unnecessary choice is ludicrous. Every developed country except the US has figured this out. 

Here is the kicker. I asked my AI friends to check. Turns out the drug is covered by many Medicare Part D and Medicare Advantage plans, but coverage is not universal.

Health care via roll of the dice. 

(You can put the last two paragraphs down as a rant🤑)