A longitudinal study of 60,000 retirees enrolled in a large private health plan with an annual pharmacy coverage limit or a similar plan with no limit finds that after high-spending patients with $2,500 caps had exhausted their benefit, but before the end of the coverage year, their use of antidepressants, antihypertensives, antihyperlipidemics, and antidiabetic agents was 15 percent to 28 percent lower than patients in uncapped plans.
Patients in a capped plan who were taking drugs that had over-the-counter substitutes had a greater reduction in drug use at the end of the year than those taking other classes of drugs. The utilization gap between capped and uncapped members narrowed to less than 10 percent for five of six drug classes by March, three months after renewal of the full benefit.
Geoffrey Joyce, PhD, lead author and a senior economist at Rand, says, "People are fairly price-sensitive when it comes to prescription drugs. Maybe we should be rethinking cost-sharing. We should think more intelligently about how copayment structure is designed."
Discontinuation and reinitiation of drugs once coverage resumes
When pharmacy benefits were capped, high spenders who discontinued treatment did so at rates that were related to therapeutic class, ranging from 15 percent for antihyperlipidemic drugs to 28 percent for cardiac drugs.
Percentage of high-cost users who stopped taking one or more prescription drugs after reaching $2,400 in plan spending (stop), and proportion who reinitiated use (resume).
Source: Joyce GF, et al. Pharmacy benefit caps and the chronically ill. 2007. Health Aff. 26(5):1333–1344.