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Med Care. 2001 Mar;39(3):296-301.

Medicare beneficiaries' management of capped prescription benefits.

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  • 1Express Scripts, Inc, Maryland Heights, Missouri 63043, USA.



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.


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.


This design was quasi-experimental, with data obtained from self-administered questionnaires mailed to 600 Medicare HMO risk enrollees with capped prescription benefits.


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.


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.

[PubMed - indexed for MEDLINE]
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