trends & decision drivers in private plans. by martin chung
DESCRIPTION
Presentation by Martin Chung at OPMA's breakfast session on April 3, 2014.TRANSCRIPT
Who is providing benefits? What is covered? How much is covered? Who is driving plan design decisions…and
why? Is mutually beneficial collaboration possible?
EXPLORE QUESTIONS THAT MATTER
WHO IS PROVIDING BENEFITS (I)
EMPLOYER SEGMENTATION BY SIZE
Vast majority of workplaces are small-mid in size
[NOTE: Employers (especially small) do not always provide benefits]
WHO IS PROVIDING BENEFITS (II)
EMPLOYER SEGMENTATION BY #EE
Majority of Employees work for small-mid Employers
Are you influencing all employer segments?
“OPEN” PLAN: Exception based plan design where all Rx requiring +/- OTC are eligible with the exception of specific drugs or categories.
CLOSED (aka. MANAGED) PLAN: Inclusion based plan design where only specific DINS are eligible.
FOUNDATIONAL DEFINITIONS
Image Source: Google
Open Plans still prevalent
Eligibility no longer automatic on Open Plans
Slow progression to Closed Plans
Larger employers more willing to limit what is covered
TRENDS ASSOCIATED WITH WHAT IS COVERED
Mandatory generic pricing Adjustment to dispensing fee Annual or per Rx deductible Co-insurance Multi-tier co-insurance +/- “Americanization” Lifetime drug maximum Annual drug maximum Etc. etc. etc….
TRENDS ASSOCIATED WITH HOW MUCH IS COVERED
1980 RARELY A NEED TO ASK
1990 WHAT VERSUS HOW MUCH IS COVERED
2000 WHAT VERSUS HOW MUCH IS COVERED >2015 WHAT VERSUS HOW MUCH IS
COVERED
THE WHAT VS. HOW MUCH TRANSITION
24 Carriers provide group benefit products PBM? Advisors (over 100,000 can sell group benefits)
Employers (to less or greater degree depending on size)
Ancillary providers
WHO DRIVES PLAN DESIGN DECISIONS?
Do you have balance, reach, and acute awareness of influence levers? Current approach will not work
IS MUTUALLY BENEFICIAL COLLABORATION POSSIBLE?
Image Source: Google
What does above brand mean? Rx&D Evidence B2B Transparency