Drug Cost Trend Is Still Concern; Coinsurance on Pharmacy Side Rose

Reprinted from SPECIALTY PHARMACY NEWS, a monthly newsletter designed to help health plans, specialty pharmacies, pharma companies, providers and employers contain costs and improve outcomes related to high-cost specialty products. 

By Angela Maas, Managing Editor

March 2017 Volume 14 Issue 3

From 2015 to 2016, employers were consistent in some of their specialty drug benefit trends, but in other areas, some interesting shifts occurred, according to the 2017 edition of Trends in Specialty Drug Benefits from the Pharmacy Benefit Management Institute (PBMI). Sponsored by Walgreens Specialty Pharmacy, the sixth edition of the annual report was released March 7 at PBMI’s 22nd Annual Drug Benefit Conference.

PBMI in September 2016 surveyed 298 employers representing approximately 10 million covered lives.

Specialty drugs can fall under both the pharmacy and the medical benefits. For many years, PBMs in particular have called for shifting coverage of these medications from the medical to the pharmacy benefit, where real-time adjudication of claims and more specific product codes lend themselves to more effective management tactics. In 2016, though, 37% of respondents said they covered specialty therapies under the pharmacy benefit but not the medical — a decrease from 42% the previous year. But coverage of the drugs under both the pharmacy and medical benefit increased, from 56% in 2015 to 61% last year, a “significant increase,” according to PBMI. Large employers (those with more than 5,000 employees) were the main drivers of that increase, with 71% of them reporting this benefit coverage as opposed to 50% of smaller employers (fewer than 5,000 employees).

In a finding that probably shouldn’t come as a surprise, the top goal for specialty drug management was to manage specialty drug cost trend, cited by 51% of respondents. Following it were reducing inappropriate use (13%), improving adherence and persistency (11%) and reducing drug acquisition cost (10%).

Interestingly, the percentage of respondents that can track outcomes for people taking specialty drugs decreased from 2015 to 2016. The ability to track overall health care costs for people on specialty medications dropped from 65% to 60%, while the ability to track adherence and persistency outcomes for people taking specialty therapies dropped from 55% to 53%.

While many payers have created a specialty drug tier, about half of the respondents (47%) said they did not have a separate cost-sharing tier last year. Of this group, only 23% said they planned to implement one in the next few years, down from 31% in 2015.

Coinsurance continues to be the main cost-sharing design within the medical benefit, with 54% of 2015 respondents and 55% of 2016 respondents using it. And while copayments have long been the main approach for drugs under the pharmacy benefit, respondents reported a decrease from 48% to 43% in copayment use. The use of coinsurance, both with and without minimums and/or maximums, within the pharmacy benefit actually increased slightly year over year, from 48% to 51%.

Download the report at http://tinyurl.com/z5mh584.

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