No, TrOOP does not count toward your Medicare Advantage plan's
MOOP limit. TrOOP and MOOP are two different measures of out-of-pocket (OOP) costs - and TrOOP and MOOP are
not related, aside from both being OOP cost measures.
TrOOP (Total out-of-pocket costs) is your out-of-pocket spending for Medicare Part D prescription drug purchases, whether provided by a
Medicare Advantage
plan that includes prescription drug coverage (MAPD) or a stand-alone
Medicare Part D plan (PDP) -- TrOOP does not include your drug plan premiums paid.
The
TrOOP limit (also known as the
RxMOOP) defines the maximum you will spend on formulary drug purchases for the year. Once your TrOOP goes beyond the RxMOOP, you exit the Initial Coverage phase and enter the
Catastrophic Coverage portion of your Medicare Part
D plan where pay nothing for your formulary drug purchases for the
remainder of the year.
Each year, the Centers for Medicare and Medicaid
Services (CMS) establishes the annual RxMOOP (TrOOP limit) The RxMOOP is
$2,000 in 2025 and
$2,100 in 2026. You can see how TrOOP limits have changed over the years here:
q1medicare.com/PartD-The-MedicarePartDOutlookAllYears.php
MOOP (Maximum out-of-pocket costs) is your actual out-of-pocket spending for Medicare Part A and Medicare Part B covered services. MOOP does not include your Medicare plan premiums.
The
MOOP limit is a Medicare Advantage plan's OOP
spending limit for Medicare Part A and Medicare Part B covered services. When
you reach your plan's MOOP, you should not have more Medicare Part A and
Medicare Part B in-network expenses for the remainder of the year.
Look for language in your Medicare Advantage Summary of Benefits that might read something like:
"Your yearly limit(s) in this plan: $6,700
for services you receive from in-network providers. If you reach the
limit on out-of-pocket costs [MOOP], you keep getting covered hospital
and medical services and we will pay the full cost for the rest of the
year."
However, depending on
your Medicare Advantage plan, out-of-network coverage might be excluded
from your MOOP. Please look for language in your Medicare Advantage plans (MA or MAPD) Summary of Benefits that reads like:
"Your yearly limit(s) in this plan: $4,000 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs [MOOP], you keep getting
covered hospital [Medicare Part A] and medical [Medicare Part B]
services and we will pay the full cost for the rest of the year. Please
note that you will still need to pay your monthly premiums and
cost-sharing for your Part D prescription drugs."
Medicare Advantage plans can have varying MOOP limits
and each year CMS establishes a limit on MOOP. In 2025, MOOP is limited to
$9,350. You can see how MOOP varies between 2022/2023/2024/2025 Medicare Advantage
plans here:
Q1News.com/1050.
Also see FAQ:
What is the Medicare Part D RxMOOP?