Graham Center One-Pager

What Physicians Need to Know About Seniors and Limited Prescription Benefits, and Why



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Am Fam Physician. 2002 Jul 15;66(2):212.

More and more often, seniors are faced with outpatient prescription benefits that have annual spending limits, and they may be forced to cut back on use of medications when they run out of benefits before the end of the year. Family physicians can play a valuable role by helping seniors choose the best value medications for their budgets and by checking whether or not seniors can afford their prescriptions.

Annual limits on prescription benefits are common

Prescription drugs can be expensive, and drug benefits available to seniors often balance benefit generosity and cost by placing an annual spending limit on drug coverage. For example, one current proposal for a national Medicare drug benefit would pay for 50 to 70 percent of a senior's first $2,000 of drug costs and then no part of drug costs until expenses reach $5,000. In the past, seniors also signed up with managed care plans to receive generous drug benefits. About 6 million (15 percent) Medicare beneficiaries were enrolled in managed care in the year 2000. However, these drug benefits commonly (86 percent) have annual spending limits, and these limits are also being decreased. About 70 percent of these spending limits were set at $1,000 or less, and 30 percent were set to cover $500 or less of drug costs for the year. Because seniors spend an average of $2,150 on prescription drugs each year, family physicians need to be aware that even seniors with drug coverage can use up their benefits quickly.

Seniors use less medication when they run out of drug benefits

Once seniors use up their annual drug benefit, they have to pay the full cost of their medication, which can be quite high. For example, one common medication for reducing cholesterol usually costs $80 for 30 pills. Studies have shown that seniors who have to pay more out-of-pocket for medications often use less medication. In one study, as many as one in four seniors reported using less medication than prescribed because of cost, and one in six reported stopping a medication because of cost. Even the use of essential medications, such as for treating high blood pressure, can decrease. One study linked an increase in prescription cost-sharing to less medication use and higher hospitalization rates. Many seniors who spend past their annual drug benefit limits may struggle with difficult decisions about trading risk for getting sick with the high cost of the medications.

How family physicians can help

Family physicians can help their senior patients make the most of their limited prescription benefits. The top prescription costs for seniors are for medications that family physicians commonly prescribe, such as drugs used to treat high cholesterol, hypertension, diabetes, ulcer/reflux disease, and emphysema/asthma. Helping seniors manage limited drug benefits is hard when faced with formularies and drug prices that differ from plan to plan. Family physicians on the front line can help find solutions. Here are ways to make a difference:

  • Ask seniors if they can afford their medications. Can they afford the cost of current prescriptions or the cost of a new medication they need? Do they know if their drug benefit has an annual limit? Can they afford their share of the prescription cost?

  • Encourage seniors to discuss their decisions about their medications and cost. Invite them to ask when they are wondering about a medication's cost and benefit. Help them decide which medications are essential to health. Advise them of the health risks if they stop or stretch a medication. Help them understand whether or not an advertised medication will really benefit them.

  • Give seniors more options on medications. Know the cost of prescriptions. What are the options if a particular brand is not affordable or will quickly use up their drug benefit? Offer choices about generics, a trial of over-the-counter medications, or discuss a second-choice medication that may be less ideal but is still effective and is more affordable for the senior.

  • Know how to help seniors shop around. Be familiar with commonly available programs that provide medications at lower prices, such as discount programs from pharmacies, drug companies, or the state, and be available to advise seniors thinking about buying medications through drug programs in Canada or elsewhere.

Now more than ever, family physicians are needed to help seniors manage their limited drug benefits and to take an active role in making the most out of these benefits.

Adapted from Graham Center One-Pager #11. Chien-Wen T, Phillips RL, Green LA, Fryer GE, Dovey SM. What physicians need to know about seniors and limited prescription benefits and why. June 2002. Available at: www.aafppolicy.org/x322.xml. From the Robert Graham Center: Policy Studies in Family Practice and Primary Care, 1350 Connecticut Ave., NW, Suite 950, Washington, DC 20036 (telephone: 202-986-5708; fax: 202-986-7034; e-mail: policy@aafp.org).


Copyright © 2002 by the American Academy of Family Physicians.
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