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

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