Pharmacy benefit caps and the chronically ill

Health Affairs

Volumn 26, Issue 5, 2007, Pages 1333-1344

  Joyce, Geoffrey F ^a   Goldman, Dana P ^b   Karaca Mandic, Pinar ^b   Zheng, Yuhui ^c  

^a RAND CORPORATION   (United States)

^b RAND   (United States)

^c Pardee RAND Graduate School   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

GENERIC DRUG;

AGED; ARTICLE; CHRONIC DISEASE; COMPARATIVE STUDY; COST CONTROL; ECONOMICS; HEALTH INSURANCE; HOSPITALIZATION; HUMAN; MEDICARE; PATIENT CARE; PATIENT COMPLIANCE; PRESCRIPTION; RETIREMENT; UNITED STATES; UTILIZATION REVIEW;

AGED; CHRONIC DISEASE; COST CONTROL; DRUGS, GENERIC; HEALTH BENEFIT PLANS, EMPLOYEE; HUMANS; INSURANCE, PHARMACEUTICAL SERVICES; MANAGED CARE PROGRAMS; MEDICARE PART D; MEDICATION THERAPY MANAGEMENT; PATIENT COMPLIANCE; PRESCRIPTIONS, DRUG; RETIREMENT; SEVERITY OF ILLNESS INDEX; UNITED STATES;

EID: 35148865161     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.26.5.1333     Document Type: Article

References (17)

1. Estimates of the fraction of Part D beneficiaries who will reach the coverage gap in 2007 and beyond vary widely. Government estimates tend to be on the lower end of this range, whereas consumer groups and patient surveys report higher fractions.
2. J. Hsu et al., "Unintended Consequences of Caps on Medicare Drug Benefits," New England Journal of Medicine 354, no. 22 (2006): 2349-2359.
3. C.W. Tseng et al., "Cost-Lowering Strategies Used by Medicare Beneficiaries Who Exceed Drug Benefit Caps and Have a Gap in Drug Coverage," Journal of the American Medical Association 292, no. 8 (2004): 952-960.
4. These data were provided to us through an ongoing arrangement with Ingenix Inc., a benefits consulting firm.
5. A considerable fraction of beneficiaries had cumulative plan drug spending between $950 and $999 in the $1,000 cap plan and between $2,401 and $2,499 in the $2,500 cap plan.
6. K.Y. Liang and S.L. Zeger, "Longitudinal Data Analysis Using Generalized Linear Models," Biometrika 73, no. 1 (1986): 13-22.
7. Some of the variation in disease prevalence may be attributable to differences in the generosity of insurance coverage - that is, more-generous coverage increases the likelihood of diagnosis and treatment.
8. The analyses presented in Exhibit 5 compare changes in monthly pharmacy use in the $2,500 cap plan and the noncapped plan. We excluded the $1,000 cap from these analyses because the plan has different levels of cost sharing for prescription drugs, and those benefits changed in 2004.
9. The use of NSAIDs fell precipitously in all three plans starting in the fourth quarter of 2004 in response to warnings on the safety of COX-2 inhibitors. However, the reduction in use was much larger among members in capped plans than others.
10. The generic rate is simply the fraction of prescriptions filled as generic.
11. S.B. Soumerai et al., "Effects of a Limit on Medicaid Drug-Reimbursement Benefits on the Use of Psychotropic Agents and Acute Mental Health Services by Patients with Schizophrenia," New England Journal of Medicine 331, no. 10 (1994): 650-655.
12. Tseng et al., "Cost-Lowering Strategies." 13. T.S. Rector, "Exhaustion of Drug Benefits and Disenrollment of Medicare Beneficiaries from Managed Care Organizations," Journal of the American Medical Association 283, no. 16 (2000): 2163-2167;
13. and E.R. Cox et al., "Medicare Beneficiaries' Management of Capped Prescription Benefits," Medical Care 39, no. 3 (2001): 296-301.
14. B. Stuart, L. Simoni-Wastila, and D. Chauncey, "Assessing the Impact of Coverage Gaps in the Medicare Part D Drug Benefit," Health Affairs 24 (2005): w167-w179 (published online 19 April 2005; 10.1377/hlthaff.w5.167).
15. J.P. Newhouse and the Insurance Experiment Group, Free for All? Lessons from the RAND Health Insurance Experiment (Cambridge, Mass.: Harvard University Press, 1993).
16. Tseng et al., "Cost-Lowering Strategies."
17. An increasing percentage of Part D plans are offering some coverage in the doughnut hole. In 2006, only 6 percent of Part D prescription drug plans (PDPs) provided coverage in the doughnut hole; by 2007, 27 percent covered use of most generic drugs in the gap.