09-10 Prescription Drug Benefit Report

As they have for the past few years, Takeda has sponsored a study by PBMI on employers and their prescription drug plans.  The report is called the 2009-2010 Prescription Drug Benefit Cost and Plan Design Report.  It has some interesting data.  (The survey is of 417 employers representing over 7M members and was completed in May/June 2009.)

• 87% of respondents have a multi-tier formulary.  (Closed formularies are almost disappeared.)
• 97% offer access to mail order.
• 17.4% use mandatory mail.  (22% of self-insured and 8% of fully insured)
• 84% allow for 60+ days supply to be dispensed at retail.  [surprisingly high to me]
• 60% of employers offer a specialty benefit.
• Members pay an average of 25.2% of retail Rxs and 19.2% of mail Rxs.
• Almost 1/2 of employers have adopted a value-based design.
• Only 89.5% use a refill too soon edit.  [Why not 100%?]
• One question I found very interesting was who was responsible for plan design:
  • Fully insured – 49.3% rely on insurance carrier (makes sense); 25.4% HR staff; and 12.7% consultant.
  • Self-insured – 56.4% rely on HR staff; 18.6% use consultants; and 7.1% use PBM. 
  • [Very surprised that PBM use was so low.]
• Almost 10% of respondents said that drug benefits were >50% of their job responsibility.  [I didn’t realize this was true any place other than the top few employers.]
• 3.8% have a maximum annual benefit for drugs.
• 30% use their PBM as an exclusive provide for specialty, but 54% require dispensing thru select specialty pharmacies. [I think this speaks to more PBMs and PBAs which don’t own their own specialty pharmacy.]
• For employers concerned about affordability, they asked what they were doing:
  • 47% do employee education – generics, mail order, network pharmacies, and preventative drugs
  • 29% don’t know
  • Only 3% use step therapy [really surprising]
• The average copays were:
  • Retail – Generics ($9.94); Preferred ($28.18); and Non-Preferred ($47.71)
  • Mail – Generics ($22.06); Preferred ($61.80); and Non-Preferred ($106.94)
• They captured low, average, and high data points for each level.  Some crazy client has a $50 generic copayment.  [Why bother?]
• MAC (Maximum Allowable Cost) is only used by 71% of clients at retail and 46% of clients at mail.  [Every client should have MAC set up.]
• Their average pharmacy reimbursement was:
  • Retail Brand – 16.4% off AWP
  • Retail Generic – 45.8% off AWP
  • Mail Brand – 23.7% off AWP
  • Mail Generic – 57.3% AWP
• The PMPM utilization numbers are interesting:
  • 1.06 active employees
  • 2.05 retirees
• 58.5% of employers cover OTCs.
• Their list of utilization management tools and usage surprises me:
  • 11% use academic detailing
  • 20% use copay relief / waivers
  • 69% use disease management
  • 44% use dose optimization
  • 38% use face-to-face pharmacist consults
  • 16% use generic sampling
  • 44% use outbound phone calls
  • 29% use pill splitting
  • 23% use prescriber profiling
  • 81% use prior authorization
  • 89% use quantity level limits
  • 47% use retrospective DUR (drug utilization review)
  • 59% use step therapy
  • 55% do therapeutic substitution