Pharmaceutical policies: effects of cap and co-payment on rational drug use

Austvoll-Dahlgren, Astrid, Aaserud, Morten, Vist, Gunn Elisabeth, Ramsay, Craig, Oxman, Andrew D, Sturm, Heidrun, Kösters, Jan Peter, Vernby, Åsa

Growing expenditures on prescription drugs represent a major challenge to many health systems. Cap and co-payment (direct cost-share) policies are intended as an incentive to deter unnecessary or marginal utilisation, and to reduce third-party payer expenditures by shifting parts of the financial burden from the insurer to patients, thus increasing their financial responsibility for prescription drugs. Direct patient drug payment policies include caps (maximum number of prescriptions or drugs that are reimbursed), fixed co-payments (patients pay a fixed amount per prescription or drug), coinsurance (patients pay a percent of the price), ceilings (patients pay the full price or part of the cost up to a ceiling, after which drugs are free or available at reduced cost), and tier co-payments (differential co-payments usually assigned to generic and brand drugs).