Cost-Lowering Strategies Used by Medicare Beneficiaries Who Exceed Drug Benefit Caps and Have a Gap in Drug Coverage

The vast majority of Medicare patients receive drug benefits with dollar limits or caps. Beneficiaries who exceed their caps have to pay the entire cost of their prescriptions for the remainder of the year. This study examined cost-cutting strategies adopted by Medicare+ Choice enrollees exceeding their caps, the extent of their financial burden, and the types of medications involved. Study participants were significantly more likely than the control group to adopt at least one strategy that decreased medication use, for example, using less medication or not starting medication. Both groups had similar rates of stopping medication completely. Study participants were more likely to switch medications (15% compared to 9%) and to use free drug samples to reduce costs. Patients who exceeded the cap were also more likely to call pharmacies to find the best prices or obtain discounts. The results confirmed previous findings that younger patients, those with lower incomes, and those with a greater number of health problems were most likely to stop using medications or not start because of cost. Fifteen of the top 20 medications accounting for prescription costs of patients exceeding the cap were for treating chronic conditions such as hypertension, heart disease and diabetes.