Clarification of True Out-of-Pocket Costs for Calendar Year 2025

Relevant to: Part D Plan Sponsors

This memorandum provides operational guidance for Part D sponsors for determining which payments by Other Health Insurers (OHI) will be considered true out-of-pocket (TrOOP) costs for calendar year (CY) 2025. Interested parties have requested that the Centers for Medicare & Medicaid Services (CMS) align existing information in the Prescription Drug Benefit Manual Table, Chapter 14, Table 30.2-2 (Other Payers Supplemental to Part D and Applicability to TrOOP) with the policy announced in Section 30 of the Final CY 2025 Part D Redesign Program Instructions (Final Program Instructions). 

See the full guidance for more information.