WHITE PAPER: Impact of Preventive Medication on Pharmacy Benefit Plan Selection

Introduction

While employers strive to offer robust health benefits, they must also stay on track financially. It can be challenging to balance the two sides. Options for employers include high deductible health plans (HDHPs) with lower monthly premiums, higher deductibles, and coverage of all Affordable Care Act (ACA) preventive medications for $0 out-of-pocket, in-network care.

Additionally, plans may elect to align first-dollar coverage with IRS defined preventive medication coverage for chronic health conditions such as diabetes, high blood pressure, high cholesterol, asthma, depression, and osteoporosis. Preventive medication coverage offers potential long-term benefits including improved adherence for chronic conditions.

We looked at refill success rates (RSR) for preventive medications as a measure of adherence in HDHPs across our EpiphanyRx book of business, by comparing plans with and without coverage of preventive medications. The definition of RSR was on-time refills within four days of expected completion of the prior fill.

Of 60 HDHP plans identified, 35 had a preventive list and 25 groups did not have a preventive list in place. Approximately 11,500 members filled preventive medications in each group for a total of 78,698 prescriptions between 1/1/2022-12/31/2022.

Employers face challenges in offering comprehensive health benefits while also effectively managing their financial resources.

Findings

In our analysis, RSRs were comparable in HDHPs with and without preventive medication coverage, with cardiovascular medications (i.e. calcium channel blockers) having the highest (85.2%) and anti-asthma medications at the lowest (64.5%) RSRs.

While little difference was found between both groups on adherence, the difference in average plan paid for preventive medications was significant, at 64.4% higher per claim for HDHPs covering those medications. Of members with chronic health conditions, 69.8% enrolled in an HDHP with preventive medication coverage versus only 30.2% in an HDHP without.

HDHPs covering preventive medications incurred a 64.4% higher cost per claim for medications compared to HDHPs without coverage.

Results showed a majority (69.8%) of individuals with chronic health issues preferred HDHPs with preventive medication coverage.

Take Aways

Covering preventive medications within an HDHP does not lead to better adherence, but it does influence plan selection by members with chronic conditions.

Members currently taking preventive medications are more likely to select an available HDHP plan with expanded preventive medication coverage than a PPO plan.

Moreover, plans can expect to invest more in the pharmacy benefit program by covering preventive medications and must weigh that benefit with increased member satisfaction in doing so.

Plans should consider avenues other than tax benefits for finding value with preventive medications, such as copay assistance or other member-centric clinical programs.

Offering HDHP plans with preventive medication coverage increases pharmacy benefit program costs.