THE KAISER FAMILY FOUNDATION
`- AND -
`
`HEALTH RESEARCH 8:
`EDUCATIONAL TRUST
`
`Benefits
`
`2016
`
`ANNUAL SURVEY
`
`Employer
`Health
`
`
`
`THE [TERRY].
`
`‘1 FQUNDATION
`
`-an—d H-RE I
`HEALTH mOH I:
`ammum TRUST
`
`Argentum Pharm. LLC V. Alcon Research, Ltd.
`Case IPR2017-01053
`
`ALCON 2108
`
`

`

`Primary Authors:
`
`KAISER FAMILY FOUNDATION
`Gary Claxton
`Matthew Rae
`Michelle Long
`Anthony Damico
`Bradley Sawyer
`
`HEALTH RESEARCH & EDUCATIONAL TRUST
`Gregory Foster
`
`NORC AT THE UNIVERSITY OF CHICAGO
`Heidi Whitmore
`Lindsey Schapiro
`
`Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit
`organization based in Menlo Park, California.
`
`Founded in 1944, the Health Research & Educational Trust (HRET) is the not-for-profit research and education
`affiliate of the American Hospital Association (AHA). HRET’s mission is to transform health care through research and
`education. HRET’s applied research seeks to create new knowledge, tools and assistance in improving the delivery of
`health care by providers and practitioners within the communities they serve.
`
`NORC at the University of Chicago is an independent research organization headquartered in downtown Chicago
`with additional offices on the University of Chicago's campus and in the D.C. Metro area. NORC also supports
`a nationwide field staff as well as international research operations. With clients throughout the world, NORC
`collaborates with government agencies, foundations, educational institutions, nonprofit organizations, and businesses
`to provide data and analysis that support informed decision making in key areas including health, education,
`economics, crime, justice, energy, security, and the environment. NORC’s 75 years of leadership and experience in data
`collection, analysis, and dissemination—coupled with deep subject matter expertise—provides the foundation for
`effective solutions.
`
`Copyright © 2016 Henry J. Kaiser Family Foundation, Menlo Park, California, and Health Research & Educational Trust,
`Chicago, Illinois. All rights reserved.
`
`Printed in the United States of America.
`
`

`

`Employer
`
`Health
`
`Benefits
`
`
`
`THE KAISER FAMILY FOUNDATION
`- AND -
`HEALTH RESEARCH &
`EDUCATIONAL TRUST
`
`
`ANNUAL SURVEY
`
`
`
`2016
`
`'I'HI: HENRY}
`
`FOUNDATION
`
`KAISER _
`FAMILY
`
`

`

`THE KAISER FAMILY FOUNDATION
`
`HEALTH RESEARCH & EDUCATIONAL TRUST
`
`

`

`TABLE OF CONTENTS
`
`LIST OF EXHIBITS
`
`SUMMARY OF FINDINGS
`
`SURVEY DESIGN AND METHODS
`
`SECTION 1
`
`Cost of Health Insurance
`
`SECTIO N 2
`
`Health Benefits Offer Rates
`
`SECTION 3
`
`Employee Coverage, Eligibility, and Participation
`
`SECTIO N 4
`
`Types of Plans Offered
`
`SECTIO N 5
`
`Market Shares of Health Plans
`
`SECTIO N 6
`
`Worker and Employer Contributions for Premiums
`
`SECTIO N 7
`
`Employee Cost Sharing
`
`SECTIO N 8
`
`High—Deductible Health Plans with Savings Option
`
`SECTIO N 9
`
`Prescription Drug Benefits
`
`SECTI O N 10
`
`Plan Funding
`
`SECTIO N 1 1
`
`Retiree Health Benefits
`
`SECTI O N 12
`
`Health Risk Assessment, Biometrics Screening and Wellness Programs
`
`SECTI 0 N 13
`
`Grandfathered Health Plans
`
`S E CTI O N 14
`
`Employer Opinions and Health Plan Practices
`
`V
`
`1
`
`11
`
`23
`
`41
`
`59
`
`71
`
`77
`
`83
`
`1 17
`
`153
`
`171
`
`187
`
`201
`
`211
`
`229
`
`235
`
`THE KAISER FAMILY FOUNDATION AHL‘ HEALTH RESEARCH 81 EDUCATIONAL TRUST
`
`

`

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`
`

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`Employer Health Benefits 2016 Annual Survey
`
`‘
`
`“>\
`
`PRESCRIPTION DRUG BENEFITS
`
`ALMOST ALL COVERED WORKERS HAVE COVERAGE FOR PRESCRIPTION DRUGS. FOR 2016, TO REDUCE BURDEN ON
`
`RESPONDENTS, WE REVISED THE SURVEY TO ASK RESPONDENTS ABOUT THE ATTRIBUTES OF PRESCRIPTION DRUG COVERAGE
`
`ONLY IN THEIR LARGEST HEALTH PLAN; PREVIOUSLY, WE ASKED ABOUT PRESCRIPTION COVERAGE IN THEIR LARGEST PLAN
`
`FOR EACH OF THE PLAN TYPES THAT THEY OFFERED.
`
`IN ADDITION, WE BEGAN ASKING EMPLOYERS ABOUT THEIR COST
`
`SHARING FOR TIERS THAT COVER SPECIALTY DRUGS EXCLUSIVELY. IN CASES IN WHICH A TIER COVERS ONLY SPECIALTY
`
`DRUGS, WE REPORT THE PLAN ATTRIBUTES UNDER THE SPECIALTY BANNER, RATHER THAN AS ONE OF THE FOUR STANDARD
`
`TIERS. THEREFORE, THE NUMBER OF TIERS A FIRM REPORTS MAY NOT CORRESPOND WITH THE NUMBER OF TIERS FOR
`
`WHICH WE HAVE COST-SHARING INFORMATION. FOR MORE INFORMATION, SEE THE SURVEY DESIGN AND METHODS SECTION.
`
`WHILE THIS NEW APPROACH PRODUCES ESTIMATES THAT ARE QUITE SIMILAR TO THOSE OBTAINED BY THE PRIOR METHOD,
`
`WE DO NOT DO STATISTICAL COMPARISONS WITH 2016 ESTIMATES AND THOSE FROM PRIOR YEARS:l
`
`b Nearly all (more than 99%) covered workers work
`at a firm that provides prescription drug coverage in
`their largest health plan.
`
`b A large share ofcovered workers (89%) work at a firm
`whose largest health plan has a tiered cost—sharing
`formula for prescription drugs (Exhibit 9.1). Cost—
`sharing tiers generally refer to a health plan placing a
`drug on a formulary or preferred drug list that classifies
`drugs into categories that are subject to different cost
`sharing or management. It is common for there to be
`different tiers for generic, preferred and non-preferred
`drugs. In recent years, plans have created additional
`tiers which, for example, may be used for lifestyle
`drugs or expensive biologia. Some plans may have
`multiple tiers for different categories; for example, a
`plan may have preferred and non—preferred specialty
`tiers. The survey obtains information about the cost—
`sharing structure for up to five tiers.
`
`b Eighty-four percent of covered workers work at
`a firm that has three, four, or more tiers of cost
`
`sharing for prescription drugs in their largest health
`plan (Exhibit 9.1).
`
`0 Covered workers at large fimis (200 or more
`workers) whose largest health plan is an HDHP/SO
`have a different cost-sharing pattern for prescription
`drugs than covered workers with other plan types:
`they are more likely to be in a plan with the same
`
`NOTE:
`
`Generic drugs: Drugs product that are no
`longer covaed by patent protection and
`thus may be produced and/or distributed by
`multiple drug companiu.
`
`Preferred drugs: Drugs included on a formulary
`or prefared drug list; for example, a brand-
`name drug without a genetic substitute.
`
`Non-preferred drugs: Drugs not induded on a
`formulary or preferred drug list; for example, a
`brand-name dmg with a generic substitute.
`
`Fourth-tier drugs: New typm ofcost-sharing
`arrangements mat typieally build additional
`layers ofhigher copayments or coinsurance for
`specifically identified types ofdrugs, such as
`lifestyle drugs or biologim.
`
`cost sharing regardless ofdrug type (17% vs. 3%)
`or in a plan that has no cost sharing for prescriptions
`once the plan deductible is met (8% vs. < 1%)
`(Exhibit 9.2).
`
`THREE OR MORE TIERS
`
`b Thirty-two percent of covered workers work at a
`firm whose largest health plan has four or more tiers
`of cost sharing for prescription drugs (Exhibit 9.1).
`
`1 See the Methods Section for more information. In cases in which a firm indicated that one of their tiers was exclusively for
`specialty drugs, we reported the cost-sharing structure and any copay or coinsurance information under the spedalty drug
`
`banner. Therefore, a firm that has three tiers of cost sharing may only have plan attributes for the generic and preferred tier.
`
`I72
`
`
`
`
`
`THE KAISER FAMILY FOUNDATION ‘AND- HEALTH RESEARCH & EDUCATIONAL TRUST
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`
`D These coinsurance minimum and maximum amounts
`
`vary across the tiers. Among covered workers at firms
`whose largest health plan has coinsurance for the first
`cost-sharing tier, 20% have only a maximum dollar
`amount attached to the coinsurance rate, 4% have
`
`only a minimum dollar amount, 26% have both, and
`50% have neither. For those with coinsurance for the
`
`fourth cost-sharing tier, 76% have a maximum dollar
`amount, 3% have a minimum dollar amount, and
`21% have neither (Exhibit 9.12).
`
`SPECIALTY DRUGS
`
`D Specialty drugs such as biologics may be used to treat
`chronic conditions and often require special handling
`and administration. We revised the questions in
`the 2016 survey regarding specialty drugs, and are
`reporting results only among large firms because a
`large share ofsmall firms were unsure whether their
`largest plan covered these drugs.
`
`° Ninety-eight percent of covered workers at large
`firms work for employers whose largest health
`plan provides coverage for specialty drugs (Exhibit
`9.13). Among these workers, 43% work at firms
`whose largest plan has a cost-sharing tier just for
`specialty drugs (Exhibit 9.14).
`
`° Among covered workers at large firms whose
`largest plan has a separate tier for specialty drugs,
`43% have a copayrnent for specialty drugs and
`46% have a coinsurance requirement (Exhibit
`9.15). The average copayment is $89 and the
`average coinsurance rate is 26% (Exhibit 9.16).
`Seventy-eight percent ofthose with a coinsurance
`requirement have a maximum dollar limit on the
`amount of coinsurance they must pay.
`
`D Specialty drugs are typically high cost; firms use a
`variety ofstrategies to contain these costs. Among
`covered workers at large firms whose largest health
`plan provides coverage for specialty drugs, 38% use
`a different pharmacy benefit manager for specialty
`drugs; 28% have a dispensing program with
`incentives to encourage enrollees to receive specialty
`drugs in an alternative setting; 68% use a step therapy
`approach where enrollees must try alternatives before
`specialtydrugs are covered; 61% use tight limits on
`the number of units administered at a single time;
`70% use utilization management programs to review
`discharges, care settings and effectiveneS; 82%
`require prior authorization; and 89% have a mail
`order option for specialty drugs (Exhibit 9.17).
`
`D For covered workers at firms whose largest plan has
`three or more tiers ofcost sharing for prescription
`drugs, copayments are the most common form ofcost
`sharinginthefirstthreetiersandcoinsuranceisthe
`next most common. Among those with a fourth tier,
`46% have a coinsurance requirement and 41% have a
`copayment (difference not significant) (Exhibit 9.3).
`
`' Among covered workers at firms whose largest
`health plan has three or more tiers of cost sharing
`for prescription drugs, the average copayments are
`$11 for first-tier drugs, $33 second-tier drugs, $57
`third-tier drugs, and $102 for fourth-tier drugs
`(Exhibit 9.4).
`
`' Among covered workers at firms whose largest
`health plan has three or more tiers of cost sharing
`for prescription drugs, the average coinsurance
`rates are 17% for first-tier drugs, 25% second-tier
`drugs, 37% third-tier drugs, and 29% for fourth-
`tier drugs (Exhibit 9.4).
`
`SINGLE AND TWO TIERS
`
`D Five percent of covered workers work at firms whose
`largest health plan has two tiers for prescription
`drug cost sharing (Exhibit 9.1). For these workers,
`copayrnents are more common than coinsurance
`for both first-tier and second-tier drugs. The average
`copayrnent for the first tier is $12 and the average
`copayrnent for the second tier is $29 (Exhibit 9.7).
`
`D Seven percent ofcovered workers at firms whose largest
`health plan covers prescription drugs have the same
`cost sharing regardless ofthe type ofdrug (Exhibit 9.1).
`
`' Among these workers, 19% have copayrnents
`and 81% have coinsurance (Exhibit 9.8). The
`
`average coinsurance rate is 22% and the average
`copayment is $12 (Exhibit 9.9).
`
`' Thirteen percent of these workers are at firms
`whose largest health plan limits coverage for
`prescriptions to generic drugs (Exhibit 9.10).
`
`LIMITS ON COINSURANCE
`
`D Coinsurance rates for prescription drugs often
`have maximum and/or minimum dollar amounts
`
`associated with the coinsurance rate. Depending
`on the plan design, coinsurance maximums may
`significantly limit an enrollee’s outcf—pocket
`spending on higher cost drugs.
`
`
`
`2 See the Methods Section for changes in these questions and responses as compared to 2015.
`
`THE KAISER FAMILY FOUNDATION -AND- HEALTH RESEARCH & EDUCATIONAL TRUST
`
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`
`EXHIBIT 9.1
`
`Distribution of Covered Workers Facing Different Cost-Sharing Formulas for Prescription Drug
`Benefits, 2000-2016
`
`2000
`
`2001‘
`
`2002"
`
`2003'
`
`2004* 3%
`
`2005
`
`4 Orb
`
`2006
`
`5%
`
`7%
`
`7%
`
`1 1%
`
`1 3%
`
`14%
`
`14%
`
`2007*
`
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`
`20"
`
`2012
`
`2013'
`
`
`
`
`
`
`
`
`
`
`
`SOU RC E:
`
`Kaiser/HRET Survey of Emplayer-Sponsored Health Benefits, 2000-2016.
`
`' Distribution is statistically different from distribution for the previous year shown (p < .05).
`
`* No statistical tests are conducted due to revisions to the questionnaire.
`NOTE: Fourth-tier drug cost sharing information was not obtained prior to 2004.
`
`- FOUR on MORE TIERS
`- THREE TIERS
`TWO TIERS
`
`pAYMENT .5 THE SAME
`
`
`“EGARDLESS OF TYPE OF DRUG
` NO COST SHARING AFTER
`
`DEDUCTIBLE lS MET
`
`- OTHER
`
`THE KAISER FAMILY FOUNDATION -AND- HEALTH RESEARCH & EDUCATIONAL TRUST
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`EXHIBIT 9.2
`
`Employer Health Benefits 2016 Annual Survey
`
`Distribution of Covered Workers Facing Different Cost-Sharing Formulas for Prescription Drug
`Benefits, by Plan Type, 2016
`
`HDHP/SO'
`
`NON-HDHP/SO'
`
`ALLPLANS
`
`S 0 U R C E:
`
`Kaiser/HRET Surveyof Employer-Sponsored Health Benefits, 2016.
`
`" Distribution is statistically different from All Plans distribution (p < .05).
`
`l <1%
`
`196-]
`
`6% 3% |<1%
`
`5% 7% 3%|<1%
`
`- FOUR OR MORETIERS
`- THREE TIERS
`TWO TIERS
`
`PAYMENT IS THE SAME
`REGARDLESS OF TYPE OF DRUG
`NO COST SHARING AFTER
`DEDUCTIBLE IS MET
`
`- OTHER
`
`THE KAISER FAMILY FOUNDATION -AND- HEALTH RESEARCH & EDUCATIONAL TRUST
`
`
`
`

`

`Employer Health Benefits 2016 Annual Survey
`
`EXHIBIT 9.3
`
`Among Covered Workers with Three, Four, or More Tiers of Cost Sharing, Distribution
`of Covered Workers with the Following Types of Cost Sharing for Prescription Drugs,
`by Drug Tier and Firm Size, 2016
`
`First-Tier Drugs,
`Often Called Generic Drugs
`
`All Small Firms (3-199 Workers)’
`
`S
`=
`
`Coinsurance
`
`Plan Pays Entire
`Cost After Any
`Deductibles
`Are Met
`
`6%
`
`1%
`
`Some Other
`Amount
`
`1%
`
`<1
`3
`16
`All Large Firms (200 or More Workers)*
`
`
`
`13% 2%ALL FIRMS 1%
`
`Second-Tier Drugs,
`Often Called Preferred Drugs
`
`All Small Firms (3-199 Workers)*
`
`5
`
`.
`
`:
`
`Copay or
`Coinsurance Plus
`Any Difference§
`
`:
`
`0%
`
`<1
`All Large Firms (200 or More Workers)*
`
`ALL FIRMS <1%
`
`Third-Tier Drugs,
`Often Called Non-Preferred Drugs
`
`All Small Firms (3-199 Workers)*
`
`All Large Firms (200 or More Workers)*
`ALL FIRMS
`
`and the cost of a comparable generic drug.
`
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`Fourth-Tier Drugs
`
`All Small Firms (3-199 Workers)
`
`All Large Firms (200 or More Workers)
`ALL FIRMS
`
`SOURCE:
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`‘ Distribution is statistically different from the All Firms distribution (p < .05).
`
`5 Category includes workers who pay a copayment or coinsurance plus the difference between the cost ofthe prescription
`
`THE KAISER FAMILY FOUNDATION AIII‘ HEALTH RESEARCH & EDUCATIONAL TRUST
`
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`EXHIBIT 9.4
`
`Employer Health Benefits 2016 Annual Survey
`
`Among Covered Workers with Three, Four, or More Tiers of Prescription Cost Sharing, Average
`Copayments and Average Coinsurance, 2000-2016
`
`g2000g2001g200 : 003g2004g2005g2006g200 : 008g2009g2010g2011g201 : 013g2014g2015g2016
`
`Average Copayments
`
`OftenCalledGeneric gsegssgs
`Second-“er Drugs:
`Often Called Preferred
`Third-Tler Drugs, Often
`$54 $57
`$53
`5
`$5
`46*“g $46 $49*‘g S49
`$38*g 540*‘g 543‘? $43 3
`$29 $28 $32*g$35*
`Called Non—Preferred
`
`Fourth-TlerDrugs
`A
`A
`A
`A g$59gs74gs59gs71*gs75gsssgsa9g$91gs79gs80gss3gs93gsloz
`
`9*gsroggslogsnrgsl
`
`rogsrogsngsrogsl
`
`gswgsngsn
`
`NSD: Not Sufficient Data.
`
`r
`gs15 $g16*‘g $18*g$20*
`
`z
`=
`$22*g $23*g $251g $25 gs26 $27 gszsrg $29 s29 $29
`
`$31 g$31
`
`$33
`
`Average Coinsurance
`
`.
`First-TierDrugs.
`1%g20%g17%g18%g20%*g16%*g19%g17%g17%
`8%g18%g19%g19%g21°
`g18%g18%g18°
`OftenCalledGeneric
`SecondTIerDrugs
`Often Called Preferred
`N50; 23%g 24%; 23%g 25%g 27%; 26%; 26%; 25%; 26%; 25%; 25%; 26%; 25%; 24%;27%*g 25%
`Third-fierDrugstteng
`Called Non-Preferred
`g28% g33% g40% e34%rg 34% 38% g38% g40% 538% g37% g38% 39% 39% 538% g37% g43%*g 37%
`Fourth-TlerDrugs
`A
`A
`A
`A g30%g43%*g42%§36%g28%g31%g36%g29%g32%g32%g29%g32%g29%
`
`SOURCE:
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2016.
`
`A Fourth-tier drug copayment or coinsurance information was not obtained prior to 2004.
`‘ Estimate is statistically different from estimate forthe previous year shown (p < .05).
`Due to a change in methods, no statistical testing was conducted between the 2015 and 2016.
`
`THE KAISER FAMILY FOUNDATION A’IL‘ HEALTH RESEARCH Er EDUCATIONAL TRUST
`
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`56%
`Largest Plan HDHP/SO“
`26
`Not an HDHP/SO*
`32%
`ALL FIRMS
`
`
`Fourth-Tier Drugs
`
`Largest Plan HDHP/SO
`Not an HDHP/SO
`ALL FIRMS
`
` |
`
`|SOURCEI
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`“ Distribution is statistically different from All Firms distribution (p < .05).
`
`5 Category includes workers who pay a copayment or coinsurance plus the difference between the cost of the prescription
`and the cost of a comparable generic drug.
`NSD: Not Sufficient Data.
`
`THE KAISER FAMILY FOUNDATION AHI‘ HEALTH RESEARCH 8r EDUCATIONAL TRUST
`
`
`
`
`
`Employer Health Benefits 2016 Annual Survey
`
`EXHIBIT 9.5
`
`Among Covered Workers with Three, Four, or More Tiers of Prescription Cost Sharing,
`Distribution of Covered Workers with the Following Types of Cost Sharing for Prescription Drugs,
`by Largest Plan Type, 2016
`
`Some Other
`Amount
`
`<1%
`
`1 1
`
`%
`
`'
`
`:
`
`Plan Pays Entire
`Cost After Any
`Deductibles Are
`Met
`
`8%
`
`1 2
`
`%
`
`.
`
`Copayor
`Coinsurance Plus
`
`AnyDifference§
`
`0%
`<1
`<1%
`
`Copay
`69%
`
`88
`84%
`
`:
`
`Coinsurance
`
`23%
`
`11
`13%
`
`First-Tier Drugs,
`Often Called Generic Drugs
`
`Largest Plan HDHP/SO*
`Not an HDHP/SO*
`ALL FIRMS
`
`Second-Tier Drugs,
`Often Called Preferred Drugs
`
`Largest Plan HDHP/SO*
`Not an HDHP/SO*
`ALL FIRMS
`
`Third-Tier Drugs,
`Often Called Non-Preferred Drugs
`
`
`
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`EXHIBIT 9.6
`
`Employer Health Benefits 2016 Annual Survey
`
`Among Covered Workers with Two Tiers of Cost Sharing for Prescription Drugs, Distribution of Covered
`Workers with the Following Types of Cost Sharing for Prescription Drugs, by Drug Tier and Firm Size, 2016
`
`First-Tier Drugs,
`Often Called Generic Drugs
`
`All Small Firms (3-199 Workers)’
`
`All Large Firms (200 or More Workers)*
`ALL FIRMS
`
`1333
`.—
`
`OD D.
`
`—D0
`
`\O
`
`
`
`NSD: Not Suffident Data.
`
`a
`
`S
`
`Copay
`
`Coinsurance
`
`91%
`
`54
`69%
`
`8%
`
`24
`17%
`
`Plan Pays Entire
`Cost After Any
`Deductibles
`Are Met
`
`1%
`
`17
`10%
`
`Some Other
`Amount
`
`0%
`
`5
`3%
`
`Second-Tier Drugs,
`Often Called Preferred Drugs
`
`All Small Firms (3-199 Workers)
`All Large Firms (200 or More Workers)
`ALL FIRMS
`
`SOURCE:
`
`:
`
`Copay or
`Coinsurance Plus
`Any leferences§
`
`NSD
`0
`0%
`
`:
`
`:
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`' Distribution is statistically different from the All Firms distribution (p < .05).
`
`5 Category includes workers who pay a copayment or coinsurance plus the difference between the cost
`ofthe prescription and the cost of a comparable generic drug.
`
`THE KAISER FAMILY FOUNDATION A’Il‘ HEALTH RESEARCH & EDUCATIONAL TRUST
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`Employer Health Benefits 2016 Annual Survey
`
`EXHIBIT 9.7
`
`Among Covered Workers with Two Tiers of Prescription Drug Cost Sharing, Average Copayments and
`Average Coinsurance, by Drug Type, 2000-2016
`
`, ooo%2oo1%2002%2003%2oo : 005%2006%2007%2008%200 : 010%2011%2o12%2o13%2014%2015%2016
`
`Average Copayments
`First—Tier Drugs,
`Often Called Generic
`
`$7% $8*% 591%59 %$1
`
`10%511%$11%s11%$1
`
`10%511%$11%$11%$1
`
`Second-Her Drugs,
`Often Called Preferred
`%$14%$15*%$18*%$20*%$22*% $22%$23%$31 $24* $26%$28%$28%$29%$31 %$3o%$31 %$29
`Average Coinsurance
`First-Tier Drugs,
`Often Called Generic
`
`g19%%17%%20%% 21%%17%;16%%22%%17%%19%%NSD;NSD%NSD%NSD%NSD%NSD%NSD%NSD
`
`Second-Tier Drugs,
`Often Called Preferred
`
`SOURCE:
`
`%28% 25% 25% 28% %25% %24% §27% %27% §32% %28% %27% %30% §27% %30% %27% %28% NSD
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2016.
`
`‘ Estimate is statistically different from estimate forthe previous year shown (p < .05).
`Due to a change in methods, no statistical testing was conducted between the 2015 and 2016.
`NSD: Not Sufficient Data.
`
`NSD: Not Sufficient Data.
`
`EXHIBIT 9.8
`
`Among Covered Workers with the Same Cost Sharing Regardless of Drug Type, Distribution of Covered
`Workers with the Following Types of Cost Sharing for Prescription Drugs, by Firm Size, 2016
`
`All Small Firms (3-199 Workers)
`
`All Large Firms (200 or More Workers)
`ALL FIRMS
`
`SOURCE:
`
`Kaiser/HRET Survey of Emplayer-Sponsored Health Benefits, 2016.
`
`Coinsurance
`
`Some Other Amount
`
`NSD
`
`92
`81%
`
`N51)
`
`<1
`<1%
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`EXHIBIT 9.9
`
`Employer Health Benefits 2016 Annual Survey
`
`Among Covered Workers with the Same Cost Sharing Regardless of Type of Drug, Average Copayments
`and Average Coinsurance, 2000-2016
`
`§2ooo§2001§2m2§2003§2004§2005E200632007E2008§2009§201o§2011E2012§2013§2o14§2015§2016
`AverageCopaymentsg $8 510* $10 $10 §S14*§$1o*§$13*§ $13
`$15
`$15 $13 $14 s13 s12 s15 $12
`512
`
`Average Coinsurance $22%§20%§23%§22%§25%§ 23%E23%§ 22%E24%§ 22%§24%§ 23%E22%§ 22%§22%§ 22%E22%
`
`
`Isounce:
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2016.
`
`‘ Estimate is statistically different from estimate for the previous year shown (p < .05).
`Due to a change in methods, no statistical testing was conducted between the 201 S and 2016.
`
`EXHIBIT 9.10
`
`Among Covered Workers with Cost-Sharing for Prescription Drug Coverage, Percentage of
`Covered Workers Enrolled in a Plan Where the Firm's Prescription Drug Benefits Cover Only
`Generic Drugs, by Drug Tier, 2016
`
`with no cost sharing after any deductibles are met.
`
`Firms with Same Cost Sharing Regardless onype of Drug
`
`Firm's Prescription Drug Benefits
`Cover Only Generic Drugs
`
`13%
`FirstTier ofthe Firm's Prescription Drug
`Benefits Cover Only Generic Drugs
`
`Firms with Two or More Tiers ofCost Sharing
`
`76%
`
`SOURCE:
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`Note:Three percent of covered workers with prescription drug coverage are enrolled in a plan
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`Employer Health Benefits 2016 Annual Survey
`
`EXHIBIT 9.11
`
`Among Covered Workers with a Separate Tier for Generic Drugs, Average Copay and
`Coinsurance, by Firm Size, 2016
`
`FIRM SIZE
`
`All Small Firms (3-1 99 Workers)
`
`All Large Firms (200 or More Workers)
`ALL Firms
`
`SOURCE:
`
`Average Copay
`
`Average Coinsurance
`
`$12“
`510'
`
`$11
`
`NSD
`17%
`
`17%
`
`Kaiser/HRET Survey of Employer-Sponsored Hea Ith Benefits, 2016.
`
`‘ Estimate is statistically significantlydifferent from all otherfirm size categories (p < .05).
`Note: Seventy-two percent of covered workers enrolled in a plan with cost-sharing afer the deducible
`are in a plan where the first tier covers only generic drugs.
`
`- NEITHER
`
`EXHIBIT 9.12
`
`Distribution of Coinsurance Structures for Covered Workers Facing a Coinsurance for Prescription
`Drugs, by Drug Tier, 2016
`
`FIRST-TIER DRUGS,
`OFTEN CALLED GENERICS
`
`SECOND-TIER DRUGS,
`OFTEN CALLED PREFERRED DRUGS
`
`THIRD‘TIER DRUGS,
`OFTEN CALLED NON-PREFERRED DRUGS
`
`FOURTH-TIER DRUGS
`
`SPECIALTY DRUGS
`
`
`0%8
`100%
`
`SOURCE:
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`- A MAXIMUM DOLLAR AMOUNT
`- A MINIMUM DOLLAR AMOUNT
`BOTH A MAXIMUM AND
`MINIMUM DOLLAR AMOUNT
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`EXHIBIT 9.13
`
`Employer Health Benefits 2016 Annual Survey
`
`Percentage of Covered Workers at Large Firms Whose Plan with the Largest Enrollment
`Includes Coverage for Specialty Drugs, by Firm Size, Region, and Industry, 2016
`
`Percentage of Covered Workers
`
`at Large Firms Whose Plan with the Largest
`Enrollment Includes Coverage for Specialty Drugs
`
`97%
`
`96
`99
`
`=
`
`5
`
`FIRM SIZE
`zoo-999 Workers
`
`Loco-4,999 Workers
`5,000 or More Workers
`
`REGION
`Northeast
`Midwest
`South
`West
`
`INDUSTRY
`
`Ag ricuIture/Mining/Construction
`Manufacturing
`Transportation/Com munications/Utilities
`Wholesale
`Retail
`Finance
`Service
`State/Local Government
`Health Care
`
`All Large Firms (200 or More Workers)
`
`SOURCE:
`
`Kaiser/HRET Surveyof Employer-Sponsored Health Benefits, 2016.
`
`‘ Estimate is statistically different from estimate for all other firms not in the indicated size,
`
`THE KAISER FAMILY FOUNDATION A’II‘ HEALTH RESEARCH & EDUCATIONAL TRUST
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`Employer Health Benefits 2016 Annual Survey
`
`EXHIBIT 9.14
`
`Among Large Firms Whose Prescription Drug Coverage Includes Specialty Drugs, Percentage of
`Covered Workers Enrolled in a Plan That Has a Separate Tier for Specialty Drugs, by Firm Size, 2016
`
`Percentage of Covered Workers Enrolled in a Plan
`That Has a Separate Tier for Specialty Drugs
`
`32%*
`
`44
`
`48
`
`FIRM SIZE
`200-999 Workers
`
`LOGO-4,999 Workers
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`5,000 or More Workers
`
`All Large Firms (200 or More Workers)
`
`SOURCE:
`
`Kaiser/HRET Survey of Employer—Sponsored Health Benefits, 2016.
`
`' Estimate is statistically different from estimate for all other firms not in the indicated size category (p < .05).
`
`EXHIBIT 9.15
`
`Among Firms Whose Plan with the Largest Enrollment Covers Specialty Drugs, Percentage of
`Firms Which Use the Following Strategies to Contain Specialty Drug Cost, by Firm Size, 2016
`
`Some Other
`Any Deductibles
`Coinsurance Amount Are Met
`
`
`
`
`FIRM SIZE
`200-999 Workers
`
`5
`
`36%
`
`3%
`
`2
`
`4%
`
`Plan Pays
`Entire Cost After
`
`5
`
`Loco-4,999 Workers
`
`,000 or More Workers
`
`All Large Firms (200 or More Workers)
`
`'
`
`SOURCE:
`
`THE KAISER FAMILY FOUNDATION ARI
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`HEALTH RESEARCH & EDUCATIONAL TRUST
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`8 5
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`Kaiser/HRET Survey of Emplayer-Sponsored Health Benefits, 2016.
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`31
`
`53
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`EXHIBIT 9.16
`
`Employer Health Benefits 2016 Annual Survey
`
`Among Covered Workers at Large Firms Enrolled in a Plan with a Specific Tier for Specialty
`Drugs, Average Copayments and Average Coinsurance, by Firm Size, 2016
`
`FIRM SIZE
`200-999 Workers
`1,0004,999 Workers
`5,000 or More Workers
`
`All Large Firms (200 or More Workers)
`
`SOURCE:
`
`Average Copayment
`
`Average Coinsurance
`
`;
`
`5
`
`$88
`
`83
`
`$89
`
`24%
`26
`26
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`NotezTests found no statistical difference from estimate for all otherfirms not in the indicated size category (p < .05).
`
`EXHIBIT 9.17
`
`Among Large Firms Whose Plan with the Largest Enrollment Covers Specialty Drugs, Percentage
`of Firms that Use the Following Strategies to Contain Specialty Drug Costs, 2016
`
`- ALL LARGE FIRMS (200 OR MORE WORKERS)
`
`SPECIALTY DRUG
`CARVE OUT
`
`SPECIALTY
`PHARMACY DISPENSING
`PROGRAM
`
`STEP
`THERAPIES
`
`TIGHT LIMITS
`ON THE NUMBER
`OF UNITS ADMINISTERED
`AT A SINGLE TIME
`
`UTILIZATION
`MANAGEMENT
`PROGRAMS
`
`PRIOR
`AUTHORIZATION
`
`SOURCE:
`
`Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.
`
`NOTES: Specialty drug carve out refers to an arrangement where a different pharmacy benefit manager administers
`specialty drugs benefits. Step therapies require enrollees to try alternatives before specialty drugs are covered.
`Utilization management programs review the discharges, care settings, and effectiveness of drugs.
`
`THE KAISER FAMILY FOUNDATION AND HEALTH RESEARCH E: EDUCATIONAL TRUST
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