As with the medical benefit, employers can use deductibles, out-of-pocket limits (OOP) and maximum annual benefits (MAB) as part of their overall cost-sharing design. In 2011, deductibles were used by 22.4% of respondents, OOP limits by 14.3%, and MAB limits by 8.1% (Figure 18). Only 7% had a high deductible as part of a consumer-directed health plan. Among those with a high deductible, 38% excluded select drug classes from the deductible. The range and median dollar amounts are shown for the deductibles and OOP limits in Table 8. Larger employers were more much more likely to have a MAB limit and an OOP limit than were employers with less than 2,000 lives (p<.05).
Central to pharmacy benefit design is the use of cost-sharing tiers, which are less frequently used on the medical side. Table 9 illustrates how the industry categorizes drugs for cost sharing and reimbursement purposes. Three or more tier plan designs are used by 84% of employers (Figure 19). As in prior years, the most commonly used cost sharing approach is a three-tier plan design (generics, preferred brands and nonpreferred brands), representing 59% of respondents. Nearly one in four employers (23%) now have a specialty tier, which in most cases is a higher dollar amount than the other tiers. The trend toward increasing use of four-tier designs continues, with a significant increase this year to 25% of all respondents. In addition, coinsurance designs are continuing to slowly replace flat dollar copays, growing from 14% of plans in 2008 to 34% in 2011. Most coinsurance plans have some tiers with fixed copays as well as minimums and maximums for their coinsurance tiers. Accordingly, an overall trend is the use of more complex cost-sharing designs.
Plan designs vary significantly across different types of employers (Table 10). Carve-in plans are more likely to use two-tier copays rather than three-tier, relative to carve-out plans (p<.05). Self-insured employers are more likely to use three-tier with coinsurance than are fully-insured (p<.05). Employers with 20,000 or more lives are more likely to use four-tier with coinsurance (p<.05).
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Average copays and coinsurance amounts are provided for these plan designs for retail and mail dispensing channels in Tables 11-15. The two-tier brand copays were much lower in 2011, an apparent anomaly of the small sample size of this category.
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