Study: Elderly Exit When They Exceed Rx Benefit Cap

In a study that confirms what has long been assumed, Medicare HMO enrollees become more likely to drop their carriers when they exceed annual pharmacy-benefit caps. Express Scripts, the pharmacy benefit manager, published its findings in the Journal of the American Medical Association in late November.

The link between exhaustion of drug benefits and Medicare HMO disenrollment has been much discussed, but is documented less with empirical evidence than anecdotal findings. Express Scripts evaluated three Medicare HMOs, which had annual pharmacy spending limits of $600, $1,000, and $1,500 in 1997, and $1,000 each in 1998.

The HMO with the smallest annual pharmacy cap in ’97 had the highest disenrollment rate — 19.3 percent — but when the cap was raised in the next year to $1,000, it re-enrolled 21 percent of those who had quit.

The research was conducted by the University of Arizona’s Emily Cox, Ph.D., who had determined in earlier research that the elderly stop taking medications when pharmacy benefit caps are reached.

Express Scripts says the findings hold public policy implications as Congress embarks on crafting a prescription benefit in Medicare this year.

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