@schumacv The medication cap applies to those on Medicare with a Part D, Pharmacy Benefit plan or Part G Medicare Advantage plan. I do not know what happens to those with only Medicare A/B without a drug plan. It only applies to "covered" medications. For example, Low Dose Naltrexone (LDN) is not covered by our plan, so the total cost is out-of-pocket. The same would be true for any drug for which the plan denied coverage under the "prior approval " clause.
For all others with a Pharmacy Benefit, the terms are outlined in your insurance contract.