stack of money with a stethoscope on top

For a number of years, our clients have asked us to analyze benefit plan designs to determine regional variances in patient responsibility for Specialty therapies. Inspired by our clients, DRG recently completed a detailed study of 700 of the nation’s largest Commercial benefit plan designs to determine the wide spectrum of patient out-of-pocket costs for Specialty medications. Here’s what we learned, in part:

  • 40.5% of plan designs in our study have an out-of-pocket maximum of $6000 or higher
  • While 15% of plan designs have no annual deductible, our study found that 65% of plan designs have an annual deductible set at $2,000 or lower
  • In roughly 22% of plan designs, patients had an in-network copayment of $50-$200 for a Specialty product, representing an annual patient out-of-pocket responsibility of $650-$2600
  • In 16% of plan designs, patients had an in-network copayment of 50% for a Specialty product
  • In our study, New Hampshire had the highest number of plan designs with an out-of-pocket maximum set at $5,000 or higher, confirming our theory that location does matter

This study is part of an annual, syndicated Out-of-Pocket Analysis performed by DRG, which, along with our Out-of-Pocket Tool can be used to inform the out-of-pocket contributions patients will pay within a given state, payer, and benefit design. DRG’s Out-of-Pocket resources are designed to support market access tactics and planning, including:

  • Market Access team engagement with payers
  • Planning for the impact of complex benefit designs, including out-of-pocket payments where there is a combination of deductible, copayment, and coinsurance for care adjudicated under the medical and/or pharmacy benefit
  • Planning for Patient Assistance Program funding and foundation support

Example of the OOP Tool for patients using Specialty Asthma drugs under Aetna AZ PPO 5000 100/50 Plan:





Please tell us your thoughts:

  • How does benefit plan design influence access to Specialty therapies?
  • Which benefit designs preclude meaningful access to your team's Specialty product?
  • How many people won’t have access to your Specialty therapy because of their benefit choice?

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