SECTION9. PRESCRIPTIONDRUGBENEFITS Section9 PrescriptionDrugBenefits Almostallcoveredworkershavecoverageforprescriptiondrugs. Overtheyearsthatwehaveconductedthesurvey,coverage for prescriptions has becomemorecomplexasemployersandinsurersexpandedtheuseofformularieswithmultiple cost-sharingtiers as well as other managementapproaches. Collectinginformationaboutthesepracticesischallengingand wasburdensometorespondentswithmultipleplanstoreporton. Beginningin2016,toreduceburdenonrespondents,werevisedthesurveytoaskrespondentsabouttheattributesof prescription drugcoverageonlyintheirlargesthealthplan;previously,weaskedaboutprescriptioncoverageintheirlargest planforeachoftheplantypesthattheyoffered. Afterreviewingtheresponsesandcomparingthemtoprioryearswherewe askedabouteachplantype,wefindthattheinformationwearereceivingisquitesimilartoresponsesfrompreviousyears. Forthisreason,wewillcontinuetoreportourresultsforthesequestionsweightedbythenumberofcoveredworkersin respondingfirms. Thereisamoredetaileddiscussioninthesurveydesignandmethodssectiononthistopic. In addition, because of the significant policy interest in access to and the cost of specialty drugs, in 2016 we also began asking employerstoreportseparatelyaboutthecostsharingfortiersthatcoveronlyspecialtydrugs. Incasesinwhichatiercovers onlyspecialtydrugs,wereportitsattributesunderthespecialtybanner,ratherthanasoneofthestandardtiers. Thisentails revising the waywegroupformularytiers: forexample,athree-tierformularywherethethirdtiercoversexclusivelyspecialty drugsisnowconsideratwo-tierplanwithanadditionaltier. Thisapproachallowsustoreportonthecostsharingforspecialty drugsregardlessofthenumberoftiersintheformulary. Forthisreason,wearenotpresentingstatisticalcomparisonsof 1 estimatesrelyingontierstoprioryears. Thischangeisalsodiscussedmorefullyinthesurveydesignandmethodssection. • Nearlyall(99%)coveredworkersworkatafirmthatprovidesprescriptiondrugcoverageintheirlargesthealthplan. DISTRIBUTIONOFCOST-SHARING • Alargeshareofcoveredworkers(91%)areinaplanwithatieredcost-sharingformulaforprescriptiondrugs[Figure9.1]. Cost-sharingtiersgenerallyrefertoahealthplanplacingadrugonaformularyorpreferreddruglistthatclassifiesdrugs into categories that are subject to different cost sharing or management. It is common for there to be different tiers for generic, preferred and non-preferred drugs. In recent years, plans have created additional tiers which, for example, maybeusedforlifestyledrugsorexpensivebiologics. Someplansmayhavemultipletiersfordifferentcategories; for example,aplanmayhavepreferredandnon-preferredspecialtytiers. Thesurveyobtainsinformationaboutthe cost-sharingstructureforuptofivetiers. • Eighty-threepercentofcoveredworkersareinaplanwiththree,four,ormoretiersofcostsharingforprescriptiondrugs [Figure 9.1]. These totals include tiers that cover only specialty drugs, even though the cost-sharing information for thosetiersisreportedseparately. – HDHP/SOshaveadifferentcost-sharingpatternforprescriptiondrugsthanotherplantypes. Coveredworkersin HDHP/SOsaremorelikelytobeinaplanwiththesamecostsharingregardlessofdrugtype(15%vs.2%)orin aplanthathasnocostsharingforprescriptionsoncetheplandeductibleismet(13%vs. <1%)ascomparedto coveredworkersinothertypesofplans[Figure9.2]. 1 SeetheMethodsSectionformoreinformation. Incasesinwhichafirmindicatedthatoneoftheirtierswasexclusivelyforspecialtydrugs,wereportedthe cost-sharingstructureandanycopayorcoinsuranceinformationunderthespecialtydrugbanner. Therefore,afirmthathasthreetiersofcostsharingmay onlyhaveplanattributesforthegenericandpreferredtiers. The Kaiser Family Foundation and Health Research & Educational Trust / Page 148