Trends & decision drivers in private plans. By Martin Chung
TRENDS & DECISION
DRIVERS IN PRIVATE
Martin Chung April 3, 2014
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
[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
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.
Open Plans still prevalent
Eligibility no longer automatic on Open Plans
Slow progression to Closed Plans
Larger employers more willing to limit what is
TRENDS ASSOCIATED WITH WHAT IS
Mandatory generic pricing
Adjustment to dispensing fee
Annual or per Rx deductible
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
24 Carriers provide group benefit products
Advisors (over 100,000 can sell group benefits)
Employers (to less or greater degree depending on size)
WHO DRIVES PLAN DESIGN
Do you have balance, reach, and acute
awareness of influence levers? Current
approach will not work
IS MUTUALLY BENEFICIAL
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