Drug Benefit Caps

20.4 - Drug Benefit Caps (Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05) (Chapter 4, §20.8 of the Medicare Managed Care Manual) As outlined above in §10.4, under certain circumstances, a Medicare cost plan may offer coverage for outpatient prescription drugs that would not normally be covered under the original Medicare program. The CMS has approved non-Medicare prescription drug benefits that provide for annual, quarterly and monthly caps on the dollar amount of benefits available to enrolled members. A Medicare cost plan may also pro-rate an annual drug benefit that has an annual cap. Pro-rating of the annual cap is permitted according to the member’s enrollment date, since this would be similar to, but more generous than, a quarterly or monthly cap. (42 CFR 417.104(a)(4)(ii)) The tracking of out of pocket maximums is the responsibility of the enrollee, not the plan. As indicated in §100 of this subchapter, the Medicare cost plan must clearly notify the beneficiary of this limitation.