Good question — the cap tracking is built into how Part D plans process claims.
Short answer: Medicare doesn’t watch you manually. Your Part D plan tracks it automatically through its claims system.
Here’s how it works:
✅ How Medicare knows you hit $2,100
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
All plans use a standardized accounting system called TrOOP (True Out-Of-Pocket costs). Once your TrOOP total hits the annual cap, the system flips a switch:
👉 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.
❗What if the drug isn’t covered?
This is the important part:
If a drug is not covered by your plan, it usually does NOT count toward the cap.
Situations:
1. Non-formulary drug (not on your plan’s list)
If you pay cash without approval →
🚫 does not count toward the cap
2. You request and win an exception
If the plan approves a coverage exception →
✅ it counts toward the cap
3. You use a discount card or pay outside insurance
🚫 does not count
4. Covered drug but high cost
✅ counts toward the cap
The system only tracks drugs processed through your Part D insurance.
QUINNSCOMMENTARY 