SECTION9. PRESCRIPTIONDRUGBENEFITS AVERAGECOST-SHARINGNOTINCLUDINGTIERSEXCLUSIVELYCOVERING SPECIALTYDRUGS • Evenwhenformularytierscoveringonlyspecialtydrugsarenotincluded,alargeshare(77%)ofcoveredworkersareina planwiththreeormoretiersofcostsharingforprescriptiondrugs. Thecost-sharingstatisticspresentedinthissection donotincludeinformationabouttiersthatcoveronlyspecialtydrugs. Incasesinwhichaplancoversspecialtydrugs onatierwithotherdrugs,theywillstillbeincludedintheseaverages. Cost-sharingstatisticsfortierscoveringonly specialty drugs are presented in the next section. • Forcoveredworkersinaplanwiththreeormoretiersofcostsharingforprescriptiondrugs,copaymentsarethemost commonformofcostsharinginthefirstthreetiersandcoinsuranceisthenextmostcommon. Amongthosewitha fourthtier, the difference betweenthepercentagewithacopaymentandacoinsurancerequirementisnotstatistically significant[Figure9.3]. – Amongcoveredworkersinplanswiththreeormoretiersofcostsharingforprescriptiondrugs,theaverage copaymentsare$11forfirst-tierdrugs,$33second-tierdrugs,$59forthird-tierdrugs,and$110forfourth-tier drugs[Figure9.6]. – Amongcoveredworkersinplanswiththreeormoretiersofcostsharingforprescriptiondrugs,theaverage coinsuranceratesare17%forfirst-tierdrugs,25%second-tierdrugs,38%third-tierdrugs,and28%forfourth-tier drugs[Figure9.6]. • Elevenpercentofcoveredworkersareinaplanwithtwotiersforprescriptiondrugcostsharing(excludingtiers coveringonlyspecialtydrugs). – Fortheseworkers,copaymentsaremorecommonthancoinsuranceforbothfirst-tierandsecond-tierdrugs. The averagecopaymentforthefirsttieris$11andtheaveragecopaymentforthesecondtieris$30[Figure9.3]. • Sevenpercentofcoveredworkersareinaplanwiththesamecostsharingforprescriptionsregardlessofthetypeof drug(excludingtierscoveringonlyspecialtydrugs). – Amongtheseworkers,21%havecopaymentsand79%havecoinsurance[Figure9.3]. Theaveragecoinsurance rate is 19% and the averagecopaymentis$11[Figure9.7]. – Twenty-onepercentoftheseworkersareinaplanthatlimitscoverageforprescriptionstogenericdrugs[Figure 9.9]. • Coinsuranceratesforprescriptiondrugsoftenhavemaximumand/orminimumdollaramountsassociatedwiththe coinsurancerate. Dependingontheplandesign,coinsurancemaximumsmaysignificantlylimittheamountanenrollee mustspendout-of-pocketforhighercostdrugs. • Thesecoinsuranceminimumandmaximumamountsvaryacrossthetiers. – Forexample,amongcoveredworkersinaplanwithcoinsuranceforthefirstcost-sharingtier,25%haveonlya maximumdollaramountattachedtothecoinsurancerate,8%haveonlyaminimumdollaramount,18%have bothaminimumandmaximumdollaramount,and49%haveneither. Forthoseinaplanwithcoinsurancefor thefourthcost-sharingtier,52%haveonlyamaximumdollaramountattachedtothecoinsurancerate,4%have onlyaminimumdollaramount,12%havebothaminimumandmaximumdollaramount,and33%haveneither. [Figure 9.8]. The Kaiser Family Foundation and Health Research & Educational Trust / Page 150