Pharmacy Benefit Data From PBMI

I had a chance to read through the new 2010-2011 Prescription Drug Benefit Cost and Plan Design Report that PBMI puts out and is sponsored by Takeda Pharmaceuticals. Here are some of my highlights:

  • Percentage of the pharmacy claims costs paid by the beneficiary
    • Retail = 25.3%
    • Mail = 20.1%
    • Specialty = 15.9%
  • Average difference between retail and mail copayments (see chart):
    • Non-preferred brands = $18.38
    • Preferred brands = $7.15
    • Generics = $3.61
  • 5.1% of employers are covering genetic tests to improve drug therapy management
    • 68.8% of them are covered under the medical benefit
  • 43.0% of employers are restricting maintenance medication dispensing to select pharmacies (retail or mail) [much higher than I expected]
  • They give examples of the percentage of respondents using the following value-based tools:
    • 31.7% – reduced copayments in select classes
    • 19.7% – incentives to motivate behavior change
  • I was surprised to see a significant drop in the percentage of clients requiring specialty medications to be dispensed at their PBM’s specialty pharmacy.
    • 2009 = 53.8%
    • 2010 = 40.0%
  • There was a similar drop from 15.7% to 11.5% of employers restricting coverage of specialty drugs under the medical plan.
  • Given all the focus on medication adherence, I was disappointed to see that only 24.2% of employers were focused on maximizing compliance in specialty. [Maybe they haven’t seen all the studies on this topic.]
  • They have some nice comments on Personalized Medicine and the critical questions to address.
  • I was also surprised that less than 1% of employers were using onsite pharmacies or pharmacists.
  • They provided the following data on average copayments for 3-tier plan designs with dollar copayments:
    • Generics at retail = $9.45
    • Generics at mail = $19.06
    • Preferred at retail = $25.93
    • Preferred at mail = $53.63
    • Non-preferred at retail = $46.43
    • Non-preferred at mail = $98.25
  • The average pharmacy discounts (based off AWP) were:
    • Retail brand = 17.5%
    • Retail generic = 46.6%
    • Retail 90-day = 19.8%
    • Mail brand = 23.3%
    • Mail generic = 53.5%
    • Specialty = 18.7%
  • The one number that seemed off to me was the Rxs PMPM which they had as 2.29 for active employees. That would mean 27.48 PMPY which seems closer to Medicare. [I typically use 12 Rxs PMPY for commercial and 30 Rxs PMPY for Medicare as a quick proxy.]
  • For the first time, they showed the percentage of employers excluding coverage of non-sedating antihistamines (e.g., OTC Claritin) and proton pump inhibitors (e.g., Prilosec OTC). Both classes have had lots of blockbuster drugs go OTC (over the counter) so it makes sense to exclude coverage.
    • NSAs = 44.7%
    • PPIs = 30.6%
  • They provide a nice summary of how employers are using UM (utilization management) tools.

The report has tons of data on different scenarios, different plan designs, rebates, and many other topics. I’d encourage you to go online and read thru it.

BTW – The respondent group of employers included 372 employers representing 5.8M lives including both active and retired. The average group size (active only) was 9,736 which is a decent size employer group. And, 12% of the respondents were part of a union bargaining agreement.


  1. The Benefit’s Package Blog Carnival « Enabling Healthy Decisions - March 1, 2011

    […] Next up, I thought the Free Range Communication blog does a great job of breaking out highlights from the recent SHRM report. A lot of topics of focus to the HR community are very health centric, and a lot of the trends around aging, increased use of caregivers, more people with chronic conditions, etc. are all very relevant. For those of you looking for similar data around pharmacy benefits, I just pulled out some data from another report from PBMI here. […]

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