Federal Employees Health Benefits Program
Enrollee Cost Sharing for Selected Specialty Prescription Drugs Gao ID: GAO-09-517R April 30, 2009Recent increases in prescription drug costs have been fueled in part by the high and rising cost of specialty prescription drugs. Specialty prescription drugs are typically used to treat chronic or life-threatening conditions, such as multiple sclerosis and cancer, for which few other treatment options exist. The drugs typically have few competitors or generic alternatives and may require frequent dosage adjustment, special storage, patient education, or special methods of administration, such as by injection. Costs for specialty prescription drugs are usually high, typically ranging from $1,200 to $40,000 for a 30-day supply. Health plans--including those participating in the Federal Employees Health Benefits Program (FEHBP), which covers nearly 8 million federal employees, dependents, and retirees-- provide coverage for many specialty drugs. Enrollees may be required to pay a portion of specialty drug costs through a copayment--a flat dollar amount--or coinsurance--a percentage share of the drug's actual costs. To manage the high and rising costs of these drugs, some health plans have begun to require enrollees to contribute a greater share of their costs, such as by increasing the use of coinsurance. Congress asked us to examine the costs that FEHBP enrollees may incur for specialty prescription drugs. In this report we describe cost-sharing requirements and limits for specialty drugs covered by FEHBP plans.
Enrollees in FEHBP plans are subject to varying cost-sharing requirements for the 18 specialty drugs. More than 6.6 million of the nearly 7.8 million enrollees in the plans we reviewed (86 percent) are generally subject to copayments that limit enrollee costs to about $55 on average for a 30-day supply of the drugs. Nearly 900,000 enrollees (11 percent) are subject to coinsurance for more than 1 of the 18 specialty drugs, which requires the enrollees to pay on average nearly 31 percent of the cost of the drugs. About 700,000 of the enrollees subject to coinsurance are in plans requiring it for all 18 of the drugs. Enrollees' coinsurance costs for specialty drugs are typically limited by per prescription dollar maximums or annual out-of-pocket limits. Depending on the plan, these varying requirements can result in a wide range of costs for enrollees for the same drug. For example, we estimate that an enrollee taking the multiple sclerosis drug Betaseron for a year could pay $420 if subject to a copayment, $2,400 if subject to a coinsurance with a per prescription dollar maximum, or $6,000 if subject to a coinsurance with an annual out-of-pocket maximum.
GAO-09-517R, Federal Employees Health Benefits Program: Enrollee Cost Sharing for Selected Specialty Prescription Drugs
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GAO-09-517R:
United States Government Accountability Office:
Washington, DC 20548:
April 30, 2009:
The Honorable Edward M. Kennedy: Chairman:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
Subject: Federal Employees Health Benefits Program: Enrollee Cost
Sharing for Selected Specialty Prescription Drugs:
Dear Mr. Chairman:
Recent increases in prescription drug costs have been fueled in part by
the high and rising cost of specialty prescription drugs.[Footnote 1]
Specialty prescription drugs are typically used to treat chronic or
life-threatening conditions, such as multiple sclerosis and cancer, for
which few other treatment options exist. The drugs typically have few
competitors or generic alternatives and may require frequent dosage
adjustment, special storage, patient education, or special methods of
administration, such as by injection. Costs for specialty prescription
drugs are usually high, typically ranging from $1,200 to $40,000 for a
30-day supply. Health plans--including those participating in the
Federal Employees Health Benefits Program (FEHBP), which covers nearly
8 million federal employees, dependents, and retirees--provide coverage
for many specialty drugs. Enrollees may be required to pay a portion of
specialty drug costs through a copayment--a flat dollar amount--or
coinsurance--a percentage share of the drug's actual costs.[Footnote 2]
To manage the high and rising costs of these drugs, some health plans
have begun to require enrollees to contribute a greater share of their
costs, such as by increasing the use of coinsurance. You asked us to
examine the costs that FEHBP enrollees may incur for specialty
prescription drugs. In this report we describe cost-sharing
requirements and limits for specialty drugs covered by FEHBP plans.
To obtain this information, we reviewed literature and consulted
experts[Footnote 3] to identify commonly used specialty prescription
drugs in key therapeutic classes,[Footnote 4] without lower cost
alternatives. We identified 18 such drugs--3 drugs in each of 6
therapeutic classes.[Footnote 5] We analyzed information from 184 FEHBP
plans[Footnote 6] regarding the cost sharing for a 30-day supply of
these drugs through the plans' prescription drug benefit for the 2009
benefit year.[Footnote 7] In particular, plans reported coinsurance or
copayments for the specialty drugs; other out-of-pocket costs, such as
deductibles; and limits on cost sharing, such as annual out-of-pocket
maximums and per prescription dollar maximums, which limit an
enrollee's cost for each prescription. To determine the number of
enrollees in each plan, we used 2008 FEHBP enrollment data obtained
from the Office of Personnel Management (OPM), the agency that
administers FEHBP. Enrollment in these plans totaled nearly 7.8 million
or 99.5 percent of total FEHBP enrollment in 2008.[Footnote 8] To
estimate the potential annual cost to enrollees for certain specialty
drugs reviewed based on various cost-sharing arrangements, we used drug
cost data obtained from the Web site of a large national FEHBP plan.
We relied on the data as reported by the plans and did not
independently verify the data. However, we did review all plan
responses for reasonableness and consistency, and we clarified apparent
irregularities by reviewing plan benefit brochures and contacting plan
representatives. Based on these activities, we determined the data were
sufficiently reliable for the purpose of our report. We conducted our
work from November 2008 to April 2009 in accordance with all sections
of GAO's Quality Assurance Framework that are relevant to our
objectives. The framework requires that we plan and perform the
engagement to obtain sufficient and appropriate evidence to meet our
stated objectives and to discuss any limitations in our work. We
believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
In summary, enrollees in FEHBP plans are subject to varying cost-
sharing requirements for the 18 specialty drugs. More than 6.6 million
of the nearly 7.8 million enrollees in the plans we reviewed (86
percent) are generally subject to copayments that limit enrollee costs
to about $55 on average for a 30-day supply of the drugs. Nearly
900,000 enrollees (11 percent) are subject to coinsurance for more than
1 of the 18 specialty drugs, which requires the enrollees to pay on
average nearly 31 percent of the cost of the drugs. About 700,000 of
the enrollees subject to coinsurance are in plans requiring it for all
18 of the drugs. Enrollees' coinsurance costs for specialty drugs are
typically limited by per prescription dollar maximums or annual out-of-
pocket limits. Depending on the plan, these varying requirements can
result in a wide range of costs for enrollees for the same drug. For
example, we estimate that an enrollee taking the multiple sclerosis
drug Betaseron for a year could pay $420 if subject to a copayment,
$2,400 if subject to a coinsurance with a per prescription dollar
maximum, or $6,000 if subject to a coinsurance with an annual out-of-
pocket maximum.
Cost Sharing for Selected Specialty Drugs:
More than 6.6 million of the nearly 7.8 million FEHBP enrollees in
plans we reviewed (86 percent) are generally subject to copayments that
limit enrollee costs to about $55 on average for a 30-day supply of the
drugs. About 11 percent of the enrollees are in plans that reported
requiring coinsurance for more than one drug.[Footnote 9] Reported
coinsurance ranged from 5 to 50 percent and averaged nearly 31 percent
of the drug cost. Just 3 percent of the enrollees are in plans that
reported covering most of the specialty drugs only under the medical
benefit of the plan, as opposed to the prescription drug
benefit.[Footnote 10] (See figure 1.)
Figure 1: FEHBP 2009 Cost-sharing Requirements for 18 Specialty Drugs
by Enrollment:
[Refer to PDF for image: pie-chart]
FEHBP 2009 Cost-sharing Requirements for 18 Specialty Drugs by
Enrollment:
Enrollees in plans with specialty drugs generally subject to copayment
($10 to $100): 86%;
Enrollees in plans with more than one drug subject to coinsurance (5 to
50 percent of the drug costs): 11%;
Enrollees in plans with specialty drugs generally covered under medical
benefit and subject to medical benefit cost sharing[A]: 3%.
Source: GAO analysis of FEHBP plan-reported data.
Notes: Analysis was based on 2009 cost-sharing data and 2008 FEHBP
enrollment for 179 plans, the most current data available at the time
we conducted our analysis.
The 18 specialty drugs by therapeutic class are (1) cancer: Gleevec,
Lupron Depot, and Tarceva; (2) multiple sclerosis: Avonex, Betaseron,
and Rebif; (3) rheumatoid arthritis, psoriasis, and inflammatory
conditions: Enbrel, Humira, and Remicade; (4) anemia and blood cell
deficiencies: Aranesp, Epogen, and Procrit; (5) hepatitis C: Infergen,
Pegasys, and Peg-Intron; and (6) growth hormone deficiencies:
Genotropin, Humatrope, and Norditropin/NordiFlex.
Five plans, with approximately 0.1 percent of total enrollment, require
no cost sharing for most of the specialty drugs we reviewed, and were
thus excluded from this figure.
[A] Drugs covered under a plan's medical benefit are obtained in a
therapeutic setting, such as a doctor's office. Medical benefit cost
sharing may include the cost sharing associated with an office visit,
such as a copayment, and may require additional cost sharing associated
with the drug.
[B] Includes one plan with about 50 percent of total enrollment that
requires a 30 percent coinsurance for one drug--Epogen--when obtained
from retail pharmacies. The coinsurance results in the lowest cost to
enrollees; however, the drug is also available through a mail order
pharmacy for a $65 copayment.
[End of figure]
Close to 900,000 enrollees are in 50 plans with coinsurance for more
than 1 specialty drug we reviewed, and about 78 percent of those are in
plans with coinsurance for all 18 drugs. (See table 1.) Of the 18
specialty drugs we reviewed, the 3 growth hormone deficiency drugs, the
3 hepatitis C drugs, and 2 rheumatoid arthritis drugs--Enbrel and
Humira--were subject to coinsurance most often. The rheumatoid
arthritis drug, Remicade, and the cancer drug, Lupron Depot, were least
often subject to coinsurance.
Table 1: Enrollees in FEHBP Plans with Coinsurance for More than 1 of
the 18 Specialty Drugs Reviewed:
Number of drugs with coinsurance: 18;
Enrollees: 692,677;
Percentage of enrollees: 77.7.
Number of drugs with coinsurance: 17;
Enrollees: 16,225;
Percentage of enrollees: 1.8.
Number of drugs with coinsurance: 15;
Enrollees: 43,933;
Percentage of enrollees: 4.9.
Number of drugs with coinsurance: 14;
Enrollees: 22,503;
Percentage of enrollees: 2.5.
Number of drugs with coinsurance: 13;
Enrollees: 18,146;
Percentage of enrollees: 2.0.
Number of drugs with coinsurance: 11;
Enrollees: 18,871;
Percentage of enrollees: 2.1.
Number of drugs with coinsurance: 10;
Enrollees: 49,033;
Percentage of enrollees: 5.5.
Number of drugs with coinsurance: 9;
Enrollees: 3,037;
Percentage of enrollees: 0.3.
Number of drugs with coinsurance: 3;
Enrollees: 27,549;
Percentage of enrollees: 3.1.
Number of drugs with coinsurance: Total;
Enrollees: 891,973;
Percentage of enrollees: 100%.
Source: GAO analysis of FEHBP plan-reported data.
Notes: Analysis was based on 2009 cost-sharing data and 2008 FEHBP
enrollment in 50 plans, the most current data available at the time we
conducted our analysis.
The 18 specialty drugs by therapeutic class are (1) cancer: Gleevec,
Lupron Depot, and Tarceva; (2) multiple sclerosis: Avonex, Betaseron,
and Rebif; (3) rheumatoid arthritis, psoriasis, and inflammatory
conditions: Enbrel, Humira, and Remicade; (4) anemia and blood cell
deficiencies: Aranesp, Epogen, and Procrit; (5) hepatitis C: Infergen,
Pegasys, and Peg-Intron; and (6) growth hormone deficiencies:
Genotropin, Humatrope, and Norditropin/NordiFlex.
[End of table]
Cost-sharing Limits for Selected Specialty Drugs Subject to
Coinsurance:
Though coinsurance requires enrollees to pay a share of the high cost
of selected specialty drugs, most plans limit these out-of-pocket
costs. For example, of the nearly 900,000 enrollees subject to
coinsurance for more than one specialty drug we reviewed, 63 percent
are in plans that limit enrollees' costs with a per prescription dollar
maximum for a 30-day supply of a drug. Some plans with per prescription
dollar maximums also have an annual out-of-pocket maximum that applies
to the specialty drugs reviewed, which would provide further limits to
enrollees' out-of-pocket spending. Another 35 percent of enrollees are
in plans that do not use per prescription dollar maximums but limit
drug costs with annual out-of-pocket maximums. Per prescription dollar
maximums reported by plans ranged from $50 to $400, averaging $143 for
a 30-day supply. Annual out-of-pocket maximums ranged from $1,500 to
$7,000, or $4,264 on average.[Footnote 11] The remaining 2 percent of
enrollees subject to a coinsurance for selected specialty drugs do not
have any limits to their cost sharing for drugs covered under their
plans' prescription drug benefit.[Footnote 12] (See figure 2.) The
enclosure to this report categorizes FEHBP plans requiring coinsurance
for selected specialty drugs by their methods for limiting enrollees'
cost sharing.
Figure 2: FEHBP 2009 Cost-sharing Limits for 18 Specialty Drugs Subject
to Coinsurance, by Enrollment:
[Refer to PDF for image: pie-chart]
FEHBP 2009 Cost-sharing Limits for 18 Specialty Drugs Subject to
Coinsurance, by Enrollment:
Per prescription dollar maximum ($50-$400)[C]: 63%;
Annual out-of-pocket maximum only ($1,500-$7,000)[B]: 35%;
No cost-sharing limits[A]: 2%.
Source: GAO analysis of FEHBP plan-reported data.
Notes: Analysis was based on 2009 cost-sharing data and 2008 FEHBP
enrollment in 50 plans, the most current data available at the time we
conducted our analysis.
The 18 specialty drugs by therapeutic class are (1) cancer: Gleevec,
Lupron Depot, and Tarceva; (2) multiple sclerosis: Avonex, Betaseron,
and Rebif; (3) rheumatoid arthritis, psoriasis, and inflammatory
conditions: Enbrel, Humira, and Remicade; (4) anemia and blood cell
deficiencies: Aranesp, Epogen, and Procrit; (5) hepatitis C: Infergen,
Pegasys, and Peg-Intron; and (6) growth hormone deficiencies:
Genotropin, Humatrope, and Norditropin/NordiFlex.
[A] One plan will limit cost sharing to a $30 copayment if the
prescribing physician requires the prescription to be dispensed as
written with no permitted substitutions.
[B] Annual out-of-pocket maximums can apply to drugs only or also to
other out-of-pocket costs for medical services, such as doctor's office
copayments.
[C] Some plans with per prescription dollar maximums also have an
annual out-of-pocket maximum that applies to the specialty drugs
reviewed, which could further limit enrollees' out-of-pocket spending.
[End of figure]
Examples of Enrollees' Annual Out-of-pocket Costs for Certain Specialty
Drugs:
Depending on the cost-sharing requirements and limits imposed by a
plan, enrollees could pay a significantly different amount for the same
drug. While most enrollees have their costs limited by fixed
copayments, those subject to coinsurance may be responsible for much
higher costs. For example, under the scenarios described in table 2,
below, based on an estimated total cost of $2,300 for a 30-day supply
of Betaseron,[Footnote 13] an enrollee's annual out-of-pocket costs for
this drug could range from $420 with a $35 monthly copayment to $6,000
with an annual out-of-pocket limit of $6,000. Under these cost-sharing
arrangements, enrollees would have the same range of out-of-pocket
costs for a 30-day supply of Humira, based on an estimated total cost
of $1,500.[Footnote 14] (See table 2.)
Table 2: Estimated Annual Cost in 2009 of Betaseron and Humira for
FEHBP Enrollees under Four Cost-sharing Scenarios:
Cost-sharing scenario: Copayment only;
Cost sharing: $35 copayment;
Per prescription dollar maximum: None;
Annual out-of-pocket maximum: None;
Estimated annual cost to enrollee: Betaseron: $420;
Estimated annual cost to enrollee: Humira: $420.
Cost-sharing scenario: Per prescription dollar maximum;
Cost sharing: 25% coinsurance;
Per prescription dollar maximum: $200;
Annual out-of-pocket maximum: None;
Estimated annual cost to enrollee: Betaseron: $2,400;
Estimated annual cost to enrollee: Humira: $2,400.
Cost-sharing scenario: Annual out-of-pocket maximum;
Cost sharing: 50% coinsurance;
Per prescription dollar maximum: None;
Annual out-of-pocket maximum: $6,000;
Estimated annual cost to enrollee: Betaseron: $6,000;
Estimated annual cost to enrollee: Humira: $6,000.
Cost-sharing scenario: No cost-sharing limits;
Cost sharing: 45% coinsurance;
Per prescription dollar maximum: None;
Annual out-of-pocket maximum: None;
Estimated annual cost to enrollee: Betaseron: $12,420;
Estimated annual cost to enrollee: Humira: $8,100.
Source: GAO analysis of FEHBP plan-reported data.
[End of table]
Agency Comments:
We provided a draft of this report to OPM for comment. OPM did not
comment on GAO's analysis of the data provided by the FEHBP plans, but
did provide technical comments to clarify the coverage of specialty
drugs by certain plans. We contacted officials of these plans to
confirm the information they had originally provided. In response to
OPM's technical comments and our follow up with the plans, we made
changes to the report as appropriate.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies of this report
to the Director of OPM. The report will also be available at no charge
on GAO's Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or dickenj@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Key contributors to this report were
Randy DiRosa, Assistant Director; Daniel Lee; Sari B. Shuman; Timothy
Walker; and Margaret J. Weber.
Sincerely,
Signed by:
John E. Dicken:
Director, Health Care:
Enclosure:
[End of section]
Enclosure:
Table 3: Cost-sharing Limits in FEHBP Plans with Coinsurance for More
than 1 of the 18 Specialty Drugs in 2009:
Per prescription dollar maximum:
American Postal Workers Union Health Plan--consumer driven health plan
(CDHP).
American Postal Workers Union Health Plan--high.
Association Benefit Plan--high.
Capital District Physicians' Health Plan (Capital Region)--high[A].
Capital District Physicians' Health Plan (Capital Region)--standard[A].
Connecticare--basic.
Connecticare--high.
Dean Health Plan--high[A].
Foreign Service Benefit Plan--high.
GEHA Benefit Plan--high[A].
Healthpartners Three for Free--standard[B].
Medica Health Plan--high[C].
Presbyterian Health Plan--high[D].
Presbyterian Health Plan--standard[D].
SAMBA Health Benefit Plan--standard[A].
Triple-S (Puerto Rico)--high[E].
Unicare Health Plans--high[A].
Unicare Health Plans--standard[A].
VISTA Healthplan of Southern Florida--high.
Annual out-of-pocket maximum only:
Altius Health Plans--high deductible health plan (HDHP).
Altius Health Plans--high.
Amerihealth HMO--standard.
Aultcare--HDHP.
AV-MED Health Plan (Miami)--high.
AV-MED Health Plan (Miami)--standard.
Blue Preferred HMO--high.
Firstcare (Central Texas)--high.
Firstcare (West Texas)--high.
GEHA Benefit Plan--HDHP.
GEHA Benefit Plan--standard.
Grand Valley Health Plan--high.
Grand Valley Health Plan--standard.
Health Alliance HMO--high.
Health Alliance HMO--standard.
Healthpartners Open Access Copay--high.
Humana (Puerto Rico)--high.
Humana Coveragefirst (Cincinnati)--CDHP.
Humana Coveragefirst (Tampa)--CDHP.
Humana Health Plan (Chicago)--high.
Humana Health Plan (Chicago)--standard.
Humana Health Plan of Texas (San Antonio)--high.
Humana Health Plan of Texas (San Antonio)--standard.
Humana Kansas City--high.
Humana Kansas City--standard.
Humana Medical Plan (South Florida)--high.
Humana Medical Plan (South Florida)--standard.
Mailhandlers Benefit Plan--value.
Personalcare's HMO--high.
No cost-sharing limits:
Amerihealth HMO--high.
Anthem Blue Cross-HMO--high[F].
Source: GAO analysis of FEHBP plan-reported data.
Notes: The 18 specialty drugs by therapeutic class are (1) cancer:
Gleevec, Lupron Depot, and Tarceva; (2) multiple sclerosis: Avonex,
Betaseron, and Rebif; (3) rheumatoid arthritis, psoriasis, and
inflammatory conditions: Enbrel, Humira, and Remicade; (4) anemia and
blood cell deficiencies: Aranesp, Epogen, and Procrit; (5) hepatitis C:
Infergen, Pegasys, and Peg-Intron; and (6) growth hormone deficiencies:
Genotropin, Humatrope, and Norditropin/NordiFlex.
[A] Plan also has an annual out-of-pocket maximum that could further
limit costs to enrollees.
[B] Plan also has an annual out-of-pocket maximum that could further
limit costs to enrollees for 12 of the 18 specialty drugs, and 3 drugs
have only an annual out-of-pocket maximum.
[C] Plan also has an annual out-of-pocket maximum that could further
limit costs to enrollees for 16 of the 18 specialty drugs, and 1 drug
has only an annual out-of-pocket maximum.
[D] Plan also has an annual maximum on the out-of-pocket spending for
each individual drug, which could further limit costs to enrollees.
[E] Plan also has an annual out-of-pocket maximum that could further
limit costs to enrollees for 17 of the 18 specialty drugs, and 1 drug
has only a per prescription dollar maximum.
[F] Plan will limit cost sharing to a $30 copayment if the prescribing
physician requires the prescription to be dispensed as written with no
permitted substitutions.
[End of table]
[End of section]
Footnotes:
[1] Drug costs have increased about 3 to 6 percent a year from 2004 to
2008, while specialty prescription drug costs increased 18 to 20
percent a year over the same period. Specialty drugs represented about
20 percent of total drug spending in 2008. The Health Industry Forum,
Managing Specialty Pharmaceuticals: Balancing Access and Affordability,
Conference Report (Washington, D.C.: 2008).
[2] For this report, "enrollees" refers to all individuals covered
under FEHBP plans: federal employees, dependents, and retirees.
[3] We contacted three researchers--two with doctorate degrees in
pharmacy and one with a doctorate in economics--who published studies
within the last 3 years relating to specialty drug issues, including
cost and health plan benefit designs. The researchers work at a
university, a research institute, and in the private pharmaceutical
industry.
[4] A therapeutic class is a group of drugs that are similar in
chemical structure, pharmacological effect, or clinical use.
[5] The 18 specialty drugs by therapeutic class are (1) cancer:
Gleevec, Lupron Depot, and Tarceva; (2) multiple sclerosis: Avonex,
Betaseron, and Rebif; (3) rheumatoid arthritis, psoriasis, and
inflammatory conditions: Enbrel, Humira, and Remicade; (4) anemia and
blood cell deficiencies: Aranesp, Epogen, and Procrit; (5) hepatitis C:
Infergen, Pegasys, and Peg-Intron; and (6) growth hormone deficiencies:
Genotropin, Humatrope, and Norditropin/NordiFlex.
[6] When a FEHBP plan offered multiple benefit options, we counted each
option as a separate plan, for a total of 269 plans. We contacted 189
of the 269 FEHBP plans. These 189 plans represented 99.5 percent of
total FEHBP enrollment in 2008. We received information regarding
specialty drug coverage from each plan we contacted, for a 100 percent
response rate. We excluded from our analysis 5 plans that responded but
did not have enrollment in 2008. We asked plans to provide cost-sharing
information for the drugs obtained in the manner resulting in the
lowest cost to enrollees--that is, through retail, mail order, or
specialty drug pharmacies. We requested cost information based on a 30-
day supply of each drug reviewed because some plans limit specialty
drug prescriptions to this quantity. However, some plans noted that
enrollees may obtain the drug in a 90-day supply and incur lower unit
costs.
[7] Drugs covered through a plan's prescription drug benefit may also
be available through the plan's medical benefit if obtained in a
therapeutic setting, such as a doctor's office. Drugs covered under the
medical benefit are subject to their own cost-sharing limits.
[8] The enrollment data were also used to calculate weighted averages.
[9] One plan, with about half of all FEHBP enrollees, requires
coinsurance for only one drug we reviewed--Epogen--when obtained from
retail pharmacies. The coinsurance results in the lowest cost to
enrollees; however, the drug is also available through a mail order
pharmacy for a $65 copayment.
[10] Drugs covered under a plan's medical benefit are obtained in a
therapeutic setting, such as a doctor's office. The cost to enrollees
may include the cost sharing associated with an office visit, such as a
copayment, and may require additional cost sharing associated with the
drug.
[11] Annual out-of-pocket maximums can apply to enrollees' costs for
drugs only or can also apply to other out-of-pocket costs, such as
doctor's office copayments.
[12] These individuals are enrolled in two plans: Anthem Blue Cross-
HMO-high with 45 percent coinsurance and Amerihealth HMO-high with 50
percent coinsurance.
[13] Drug cost data were obtained from the Web site of one FEHBP plan
with high enrollment.
[14] Health plans may have different costs for the same drug depending
on their prescription drug provider.
[End of section]
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441 G Street NW, Room 7149:
Washington, D.C. 20548:
