Benefit designs continue to evolve and influence

September 1, 2005

NATIONAL REPORTS—In a continuation of a trend of using financial incentives to influence individual patient decisions about the medications they purchase and take, state workers in Georgia soon will pay a $100 copay for certain name-brand drugs.

NATIONAL REPORTS-In a continuation of a trend of using financial incentives to influence individual patient decisions about the medications they purchase and take, state workers in Georgia soon will pay a $100 copay for certain name-brand drugs.

"Prescription benefit designs have evolved over the years from a single copay to two tiers-generics and brands-to three-tier-generic, preferred brand and non-preferred brand-as well as others, according to Lou Hutchison, president of HealthTrans in Greenwood Village, Colo. "The three-tier, the most common structure currently, has seen increases in the amounts [$5/$10/$25 to $10/$25/$50] and the Georgia situation, where the $100 copay applies to non-preferred brands, is simply a continuation of this trend."

The Georgia employee $100 copayment takes a drastic step toward virtually removing the concept of a drug "benefit" and is a sign of the state moving toward a new model of cost shifting directly to the employee more than ever before, according to Phil Patrick, president of PharmaStrat Inc., a pharmaceutical market research and consulting firm focused on reimbursement. "While our research shows that copayments have continued to rise, a $100 copayment for drugs with proven clinical efficacy in important disease states is almost unheard of," Patrick says.

The Georgia State Health Benefit Plan is a self-funded plan and faced a projected deficit of $46 million in 2006, according to Julie Kerlin, spokeswoman for the Georgia Department of Community Health. "The changes in pharmacy copays and increases in employer and employee premiums were necessary to ensure the financial viability of the plan," Kerlin says.

Kerlin points out that when reviewing the year-over-year trends, "the department has slowed the rate of growth in pharmacy expenditures from 12.9% in 2004 to a projected 2.5% in 2006."