Featured Health Business Daily Story, Jan. 8, 2014

New AIS Database: Bronze, Specialty Rx Copays Are Much Higher in 2015 Plan Designs

Reprinted from DRUG BENEFIT NEWS, biweekly news and proven cost management strategies for health plans, PBMs, pharma companies and employers.

By Lauren Flynn Kelly, Managing Editor
December 19, 2014Volume 15Issue 24

Health plans selling now on public exchanges for plan year 2015 have significantly higher drug copay levels than 2014 plans, according to research from AIS’s Rx Benefit Design Data (RxB), a new online subscription database.

Bronze-level plans have the biggest increases, on average, in prescription drug copays for in-network retail fills on all formulary tiers. Drug copays for bronze-level plans now average $18.59 for generics, a 30.55% increase over the 2014 amount. Bronze-level, generic tier, in-network retail fills are the most common situation for which a fixed copay amount will apply; 76% of plans have a set copay in this situation.

On other tiers, bronze plans are now charging an average prescription drug copay of $60.46 for preferred brand drugs, $103.26 for non-preferred drugs and $146.73 for specialty drugs, where copays are utilized. This represents an increase of 41.67% for preferred drugs, 58.08% for non-preferred drugs and 87.67% for specialty. The specialty formulary tier for other metal levels also shows dramatic increases in copay amounts. Specialty drug copays are up 25.44% for silver plans, 17.61% for gold plans and 28% for platinum plans. However, only 16% of plans are utilizing a set copay amount at the specialty tier — down from 23% last year.

AIS sampled 4,455 plans now selling for the 2015 plan year and 3,149 plans offered in 2014, and compared average in-network, retail drug cost-sharing parameters year-over-year. In this sample, set copays are being used slightly less frequently on every formulary tier than they were in 2014. Instead, AIS has observed a trend toward more percentage-based coinsurance requirements for prescription fills.

SOURCE/METHODOLOGY: Calculated by AIS based on data from RxB, AIS’s new online subscription database of drug benefit parameters. All cost-sharing data in this analysis is for the in-network retail pharmacy benefit. RxB is an interactive searchable database of drug benefit parameters for health plans both on and off exchanges. Visit http://aishealthdata.com/rxb for more information, or view the demo at http://aishealthdata.com/dashboard/rxb/demo.

Average Rx Copays Per Formulary Tier and Metal Level for Plans on Individual Exchanges, 2014 vs. 2015


% Change from 2014 in Average Rx Copays Per Formulary Tier and Metal Level


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