Introduction
The Pharmacy Benefit Management Institute (PBMI)
conducted its annual drug benefit plan design survey of U.S.
employers in May and June 2008. The survey was completed
by 223 employers representing 15,137,168 members.
The comprehensive survey instrument collects data about
trending information on retail and mail-order plan design
and utilization. Respondents also answer questions about:
- Medicare Part D, specialty pharmacy, maintenance drugs,
drug benefit, and out-of-pocket maximums;
- Cost sharing information;
- Per member per month utilization metrics; and
- Utilization management tools.
Key Findings
Employers establish drug plan designs to share some portion
of drug costs with members, usually based on an amount for
each tier or drug category. On average, members paid 26.6%
of a retail prescription and 19% of a mail prescription.
Three or more tier plan designs are used by 86.5% of employers. The most commonly used cost sharing approach is a three-tier copayment plan design (generics, preferred brands and nonpreferred brands) as shown in Table 1.
Survey data show increases in both retail and mail copayments
for generic, preferred brands, and nonpreferred brands cost
sharing amounts as shown in Table 2. Average coinsurance
for retail cost sharing amounts showed very small increases.
The mail cost sharing coinsurance for nonpreferred brands
was the only category that showed a small increase.
The steady decline of pharmacy reimbursement, particularly
for mail-service, continues its 10-plus year trend. Negotiated
AWP prices for retail brand and generic prescriptions are flat or show a very modest decline. The average mail pharmacy
reimbursement for brand-name drugs has declined 2.5%
since 2007. Specialty pharmacy reimbursement for 2008 is
very similar to retail brand rates with a slightly higher average
dispensing fee. The average specialty pharmacy discount off
of AWP is 16.8% with an average dispensing fee of $2.61.
Employers are using a broad range of utilization management
tools in their plan designs for all diseases and conditions. The
most popular tools are refill too soon (82.4%), quantity limits
(81.4%), and prior authorization (79.4%). This mirrors the
usage of tools by 2007 employers.
Implications of Findings
Employers are continuing to keep their rate of drug cost
increases to an average of 4.86%, the lowest rate of cost increases since PBMI began conducting this survey in 1995.
Generic utilization rates continue to increase as well. There
appear to be modest increases in the use of disease management
programs for five highly prevalent diseases that are
commonly treated with drug therapies (asthma, depression,
diabetes, high blood pressure, and high cholesterol).
In summary, employers are using multiple approaches in
concert to achieve optimal drug plan performance. Research
findings show the following approaches are effective:
- Multi-tiered formularies linked to cost sharing to drive
utilization to the lowest net cost drug,
- Incentives for generic dispensing in retail and mail-service,
- Negotiated discounts off of drug ingredient costs,
- Disease management, and
- Utilization management tools.
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