As cost sharing becomes “more complex and targeted, with remarkable changes in the use rates for higher-tier designs,” a new employer survey conducted by the Pharmacy Benefit Management Institute (PBMI) finds that only 42% of respondents employ a three-tier copayment structure, compared with nearly half of plans reporting last year and 68% of plans in 2008 (see chart, this page). Meanwhile, 23% of plans say they use four copay tiers, which typically feature specialty drugs on the fourth tier, up from 15% just one year ago.

The 2014-2015 Prescription Drug Benefit Cost and Plan Design Report, sponsored by Takeda Pharmaceuticals U.S.A., Inc., is based on a survey of 353 employers representing 29.5 million members that was conducted in April 2014. Smaller employers, defined as those with 1 to 5,000 covered enrollees including employees/retirees and dependents, made up 53% of the sample, while the other 47% of respondents had covered lives ranging from 5,001 to more than 10,000.

Specialty drug cost sharing tends to vary widely, with copayments ranging from $20 to $500 in 30-day retail programs. PBMI suggests this is an important observation because high cost-sharing levels for specialty drugs (e.g., those in the range of $100 to $250, depending on the therapy class) “may discourage the filling of prescriptions for necessary medication.”

The survey also showed that member share of specialty cost is declining for example, members on average paid 13% of the total claim cost of specialty medications in 2013, compared with a 17% cost share in 2010 — but suggested that may not represent a trend so much as it “likely reflects the rapidly rising costs of specialty medications.”

As a result, these findings highlight the significance of management strategies such as utilization management, reimbursement management and patient assistance programs as they pertain to the specialty drug benefit. PBMI says it will examine these further in its specialty drug benefit survey.

For more information, contact Julie Blackman at jblackman@pbmi.com.
Excerpted from the 1/23/2015 issue of AIS’s Drug Benefit News