Specialty Drug Digest, Part 2

Moving along with some more good data from the EMD Serono Specialty Drug Digest (link in yesterday’s post).  Next up was a review of some specific payer management tactics.  Four general categories were identified, benefit design, network management and reimbursement, utilization and clinical management, and distribution and ancillary services.  Benefit design is shorthand for how much the member gets to pay for the privilege of being prescribed these drugs.  That amount can vary depending on whether the medication is covered as a medical benefit or a pharmacy one.  For example, drugs that are routinely self-injected, like ones for MS or rheumatoid arthritis, are more likely to be covered as pharmacy benefits; while infused compounds are more likely covered as a medical benefit.  Most plans, over 60%, both high deductible and traditions designs, use a separate tier for specialty drug cost-sharing amounts.  A small number of plans use multiple specialty tiers.  Plans that lump specialty and traditional drugs together for tiering purposes tend to have more tiers, which means you probably end up with the same cost-sharing as if you separated them.

Among high-deductible plans, there is a move to more coinsurance.  In 2017, 26% of these plans use a copayment, 30% use coinsurance with a maximum out-of-pocket and 44% use coinsurance with no maximum.  Coinsurance without a maximum was up from 2016, while the other two tactics were down.  Deductibles in HD plans average $1535 (that is just for drugs), while the maximum out-of-pocket, when used, averages $3312 for an individual and $6482 for a family.  Coinsurance rates average 34% in 2017, up from 26% in 2016.  Copayments in a separate specialty tier average $103, down from $136 in 2016.  You can see why plans are moving to coinsurance.  Among traditional design insurance plans, 45% use a copayment with no maximum OOP for specialty drugs, 32% use coinsurance and 23% coinsurance with a maximum.  As with high deductible plans, there was a big increase in coinsurance without a maximum use from 2016.  The average prescription drug-specific deductible for these plans was about a third lower than for high-deductible plans at $1002, while the average maximum OOPs for individual and family were fairly similar, at $3099 and $6038, respectively.  Copayments were an average $87 for traditional , plans with a specialty tier, almost identical to the amount for plans without such a tier.  These average copayments were up significantly from 2016.  Average coinsurance was 30%, also up significantly.  More tomorrow.