Background: Having annual dollar limits in prescription coverage is a type of benefit design unique to Medicare beneficiaries. This type of coverage is found predominantly within private Medigap policies and Medicare+Choice plans offering prescription coverage.
Objectives: The purpose of this study was to determine the impact of capped prescription benefits on efforts to reduce out-of-pocket prescription expenses by beneficiaries at risk for reaching their cap.
Research design: This design was quasi-experimental, with data obtained from self-administered questionnaires mailed to 600 Medicare HMO risk enrollees with capped prescription benefits.
Results: Data were collected on 378 Medicare enrollees for a 63% response rate. Approximately half of all respondents participated in > or =1 strategy to reduce their out-of-pocket prescription expenses. Participation in selected strategies included obtaining samples from physicians (39.2%), taking less than prescribed amounts (23.6%), and discontinuing prescribed medications (16.3%). Additionally, 15% of respondents indicated going without necessities, and 12% indicated borrowing money to pay for their prescriptions. Those who reached their prescription cap were more likely to participant in any one behavior (odds ratio [OR], 2.18), more likely to take less medication than prescribed (OR, 2.83), more likely to discontinue a medication (OR, 3.36), and more likely to obtain samples from their physician (OR, 2.02) compared with those who had not reached their prescription cap.
Conclusions: Beneficiaries at risk for reaching their prescription cap are taking steps to reduce their out-of-pocket prescription costs. Although some behaviors would be considered prudent, other behaviors may be placing beneficiaries at risk for drug-related morbidity and mortality.