Reduced Prescription Drug Coverage Common Among Employers in 2011

October 21, 2011 ( – Employers are adopting plan design changes that reduce drug benefit coverage and improve pricing, according to findings from the 2011-2012 Prescription Drug Benefit Cost and Plan Design Report published by the Pharmacy Benefit Management Institute (PBMI). 

Key survey results include:

•  Plans using a four-tier design increased from 17% to 25% between 2010 and 2011. Nearly 50% of large employers (more than 20,000 lives) now have a four-tier plan design.

•  Specialty copays increased by 37% in 2011. The average specialty copay grew from $61 in 2010 to $84 in 2011. Nearly one in four employers now place specialty drugs on a fourth tier.

•  PBM pricing pressure in mail is mounting as the average discount off AWP rose by 10 percentage points for generics dispensed through mail,increasing from 58% in 2010 to more than 68% in 2011.

• Reduced coverage of specialty pharmaceuticals on the medical side is on the rise as 24% of employers now restrict coverage of specialty drugs under the medical benefit, up from 12% in 2010.


“Employers are implementing prescription management approaches consistent with their strategy for overall medical benefits. As a result, the complexity of cost-sharing continues to grow driven by increased use of four-tier plans and coinsurance designs which require additional member education,” said Brenda Motheral, PhD, Executive Director of the PBMI, in a press release.

The 2011 survey was completed by 274 employers and other plans representing 5.2 million members.  

Copies of the report are available at