Employers and PBMs use fairly standard terminology to identify cost share amounts. Table 14 illustrates how the industry categorizes drugs for cost sharing and reimbursement purposes. These values are calculated from all cost share data provided by all employers. Managed care’s original tiered drug benefit with generic and brand-name drug categories has been replaced with three-, four- and five-tier configurations as shown in Table 15.

Plan designs with three or more tiers are used by 84.7% of employers. As in prior years, the most commonly used cost sharing approach is a three-tier plan design (generics, preferred brands and nonpreferred brands). The trend toward increasing use of more three- and four-tier designs continues for a third year. Employers with carve-in plan designs are more likely to adopt two-tier and three-tier copayment cost sharing than those with carve-out plan designs. Average cost sharing amounts are provided for these multi-tier plan designs for retail and mail dispensing channels in Tables 16-22. There are no responding employers with five-tier plan designs with copayments. Self-insured employers and those with carve-out drug plans are most likely to use multi-tiered cost sharing as shown in Tables 23 and 24.

This plan design configuration analysis is based on a subset of 268 employers from the respondent population that supplied sufficient cost sharing data to infer the number of tiers in retail and mail-service and categorize as a copayment or coinsurance approach. As a result, average coinsurance and copayment numbers may not match the cost share data supplied in Tables 25-36.

Download Full Prescription Drug Benefit Cost and Plan Design Report or Request Print Copies