Impact of an Annual Dollar Limit or "Cap" on Prescription Drug Benefits for Medicare Patients

Patients At-Risk for Cost-Related Medication Nonadherence: A Review of the Literature

“…Details about the drug benefit design beyond source and duration were studied far less, and the evidence was sometimes inconsistent. Drug plans with a low maximum drug benefit cap (e.g., $200 in total drug costs per quarter) were reexamined in 3 studies, 26,28,44 and all three detected a significant risk for CRN with this drug benefit design. Only one study examined how CRN relates to patient knowledge of what the drug coverage actually covers, and it found an association with caps or limits on drug benefits but not with copays.…”

Medicare Beneficiaries and Free Prescription Drug Samples: A National Survey

“…This is partially explained by the out-of-pocket expenses known to result from prescription benefit design features such as benefit caps, high deductibles, and formulary restrictions. 26,27 Another explanation is that the population of individuals with drug coverage who access drug samples represents a mixture of 2 subgroups: individuals struggling to afford their co-pays and individuals who prefer drug samples in lieu of paying for medications. At least 1 other study also reported a high prevalence (50%) of free drug sample receipt by elderly Preferred Provider Organization (PPO) enrollees with tiered drug benefits.…”

Cost-Related Medication Nonadherence Among Elderly and Disabled Medicare Beneficiaries

“…1,20 We defined 3 levels of drug coverage: no coverage, partial coverage (Medicare health maintenance organization, self-purchased Medicare supplement with drug coverage, or state-sponsored low-income plans), and generous drug coverage (employer-sponsored coverage or Medicaid drug coverage). Plans classified "partial coverage" have been consistently found to offer more limited benefits, including higher cost sharing and lower spending allowances, 1,[20][21][22] compared with Medicaid and employer-sponsored plans, which have been shown to be fairly similar in their coverage generosity and breadth. 3,20 We separately categorized those with Medicaid and employer-sponsored coverage because of differences in population and coverage characteristics.…”