Home health care. $0 for home health care services. 20% of the Medicare-approved amount for Durable Medical Equipment (DME) Glossary. $0 for Hospice care. You may need to pay a Copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you're at home.
The health insurance industry remains an essential part of the US economy. It employs millions of workers and helps consumers deal with the soaring healthcare costs in the country. And yet, the latest health insurance statistics show that over 30 million Americans have no coverage.
If you want to learn the most shocking and relevant stats on health coverage in the US, keep reading. Below, we will cover essential topics about the US health insurance market, including average premiums, industry trends, and interesting facts.
Average Copay For Health Insurance Coverage
Health Insurance Statistics (Editor’s Choice)
- UnitedHealth Group holds the largest American health insurance market share.
- The average annual premiums for family and single coverage are $7,188 and $20,576.
- Employers cover about 70% of the US health insurance of workers.
- Alaska is the US state with the highest average employer contribution of $16,967 a year.
- About 65.3% of Americans under 65 have some type of private health insurance.
- Healthcare.gov health insurance issuers on average deny 18% of all claims.
Among private sector employees enrolled in employer-sponsored health insurance, 68.2 percent had a co-pay for each doctor visit with an average co-pay of $23. In addition, 26.1 percent had a coinsurance percentage that averaged 18.9 percent. UnitedHealth Group holds the largest USA health insurance market share. This company was. Copay in Health Insurance refers to the percentage of the claim amount that has to be borne by the policyholder under a health insurance policy. Few insurance policies come with a mandatory clause for copayment, while others offer policyholders the option for voluntary copayment, which allows them to reduce their premium payment. Those employed at small firms pay 39% of the premium for family coverage compared to 28% for workers at large companies. In 2017, the average family premium for Employer Sponsored Insurance (ESI) coverage was $17,581. Employers cover most of the cost, with workers covering 31% of the cost.
General Health Insurance Facts & Stats
1. UnitedHealth Group holds the largest USA health insurance market share.
This company was responsible for 14.1% of the overall business in the sector, as suggested by Statista’s health insurance industry overview. Next on the list of top-three providers are Anthem and Humana. Their market shares in 2018 were 9.2% and 7.8%, respectively. Other notable brands in the health insurance industry include HealthCare Services Corporation (5.3%), Centene Corporation (4.9%), and CVS Health Corporation (3%).
(Statista)
2. The number of health insurance home-office employees in the US surpassed half a million in 2018.
There were a total of 529,800 individuals working as home-office personnel in the health insurance industry. According to the health insurance industry employment statistics, this figure has been on the rise continuously for the past 10 years. In 2016, for example, the sector employed 428,200 home-based professionals.
(Statista)
3. In 2018, the total direct written premiums totaled $714 billion.
This amount noted a year-over-year improvement of 6.7%. The net earned premiums were $706 billion or by 6.5% higher than those recorded in 2017. Net investment income and underwriting gain reached $5.14 billion and $21.47 billion, respectively. The total hospital and medical expenses nearly hit $600 billion (%596 billion). Per the health insurance profits statistics, the profit margin was 3.3% or 0.9% higher than in 2017. Finally, the total number of enrolled individuals counted 225 million.
(NAIC)
4. The average annual coverage for employees is over $7,000.
Average single employee coverage in 2019 was $7,188 per year. Preferred provider organization (PPO) plans recorded the highest annual coverage of $7,675, while the high-deductible health plans (HDHP) had the lowest average of $6,412. Health insurance facts show that the situation was similar among the average yearly family insurance. Namely, the PPO was $21,693, whereas the HDHP was $18,980. The average monthly private health insurance premiums for single and family coverages were $599 and $1,715, respectively.
(Kaiser Family Foundation)
![Health Health](/uploads/1/3/4/8/134857681/131465783.png)
5. Most workers in the US work in a firm with average coverage between $6,000-$6,999.
About 26% of all employees belong in this group, show the health insurance coverage statistics. Approximately 21% and 17% of employees work in firms where the annual average premiums are $5,000-5,999 and $7,000-7,999, respectively.
Only 2% are employed in a company with an average coverage of up to $3,999 per year. The distribution of workers in businesses with single average coverage of $4,000-4,999 and $8,000-8,999 is 6% and 14%. Finally, only 6%, 4%, and 3% of employees are in companies with average premiums of $9,000-9,999, $10,000-10,999, and $11,000 or more.
(Kaiser Family Foundation)
6. The cost of private health insurance in the US has been on the rise ever since 1999.
In 1999, the average premiums for single coverage were only $2,196 per year, according to US health insurance statistics. The average premiums for family coverage, on the other hand, were significantly lower at $5,791. Both types of premiums just kept rising over the years only to reach the current figures. In 2010, just for comparison, the respective single and family average annual coverages were $5,049 and $13,770.
(Kaiser Family Foundation)
7. More than half of all American companies offer health benefits to their employees.
About 57% of the companies offer this option, which is less than the 68% and 69% recorded in 2000 and 2010. Approximately 99% of all large firms and 56% of all small firms provide health coverage to employees. The lowest share of businesses with health benefits of 47% is seen among companies with 3-9 workers, according to health insurance data.
(Kaiser Family Foundation)
8. Less than 30% of American firms offer health benefits to part-time workers.
Only 28% of all firms give such benefits. Large enterprises with 5,000 or more employees note the highest share (62%) of providing health coverage to part-time professionals. Only 28% of companies with 3-24 employees and 26% of businesses with 25-199 workers offer the same. Part-time workers get benefits at 31% and 43% of companies that employ 200-999 and 1,000-4,999 people, respectively.
(Kaiser Family Foundation)
9. In 2019, 80% of all workers in firms offering coverage were eligible for health benefits.
Still, the more shocking facts about health insurance show that among those, only 61% were covered. In small firms, about 82% were eligible, and 60% got health benefits. As for large companies, approximately 79% qualified for health coverage, but only 61% got it. During the period between 1999-2019, the situation has been virtually the same with only slight changes in both eligibility and coverage rates.
(Kaiser Family Foundation)
10. Three-thirds of companies that offer health benefits provide only one plan type.
While 75% offer only one plan type, about 21% have two different plays workers can choose from. Only 4% of the firms that provide health coverage have three or more plans on the offer. Large companies with 5,000 or more employees are the most likely to offer different health insurance plans. Health insurance statistics show that among all covered employees, 36% work in a company with a single plan. 44% and 20% meanwhile work in firms that offer two and three or more coverage plans.
(Kaiser Family Foundation)
11. Employers cover the largest share of worker health insurance premiums.
In 2019, the average share of family premiums covered by workers was about 30%. The average share of single coverage paid by employees was even lower at 18%. The situation has been similar over the past 20 years.
The United States health insurance statistics for 2019 show that the average monthly employee contribution for family coverage was $501. The average worker contribution for single coverage was much lower at $103. Both segments have been growing over the past 20 years.
(Kaiser Family Foundation)
12. In 2019, the average annual employer contribution for single premiums was nearly $6,000.
The total amount was $5,946 out of an average premium of $7,188. The average annual contribution workers paid for single coverage was, in contrast, $1,242. Employers cover most of the average family coverage premiums of $20,576 too. The average annual amount they paid per family coverage in 2019 was $14,561. Health insurance stats show that workers paid an average of only $6,015 a year.
(Kaiser Family Foundation)
13. Nearly one-third of all American firms offer financial incentives to workers if they choose a cheaper health insurance plan.
About 32% of companies persuade employees to select a health plan that costs less. Businesses save even more if most workers accept the cheapest coverage. This practice is most common among companies with 5,000 or more employees, with about 39% offering it.
(Kaiser Family Foundation)
14. New Jersey has the highest average annual family health insurance premiums.
In 2018, the average premium for health coverage in the state was $22,294. Health insurance statistics by state reveal that New York came in second with an average total annual premium of $21,904. Other states with high family health coverage premiums are District of Columbia ($21,810), Massachusetts ($21,801), and Alaska ($21,486).
(Kaiser Family Foundation)
15. North Dakota has the lowest average annual health coverage premiums.
The state’s average in 2018 was $17,337. Mississippi saw an insignificantly higher average of $17,384, while Idaho’s average was $17,579. Tennessee, New Mexico, and Hawaii were also among the states with low annual family health insurance premiums. Their respective averages in 2018 were $17,663, $17,861, and $17,919, according to health insurance data by state.
(Kaiser Family Foundation)
16. Alaska, New York, and West Virginia are the states with the highest average employer contribution towards total health insurance premiums.
In 2018, in Alaska, the average employer contribution was $16,967. Employers from New York and West Virginia came right next with average contributions of $16,898 and $16,338. Employees from Virginia, District of Columbia, and Louisiana meanwhile recorded the highest contributions with average shares of the total annual premiums of $6,597, $6,358, and $6,288, respectively.
(Kaiser Family Foundation)
17. In 2018, nearly two-thirds of US citizens under 65 had private health coverage.
A total of 65.3% had any type of private health coverage, while 58.1% among those had employer-funded coverage, according to health insurance demographics stats. Respective 20.2% and 2.9% of Americans under 65 had Medicaid and Medicare coverage. Also, about 3.7% had other public coverage. The latest medical bankruptcies statistics show that these programs help millions of Americans deal with soaring healthcare costs. Finally, only 3.7% of the participants had no health insurance.
(CDC)
18. Over two-thirds of Americans aged 18-64 have private health coverage.
About 68.9% of these adults held private insurance, as indicated by health insurance industry statistics. This share has been ranging from 65-75% for the past 20 years. There’s been an interesting change in the percentages of uninsured Americans and those with public insurance. While in 2014, both categories represented about 15% each, in the years since, the share of uninsured adults has dropped to about 13.3%. The rate of publicly insured Americans, in contrast, jumped to 19.4%.
(CDC)
19. The public health insurance rates among children aged 0-17 are two times higher than those recorded among adults.
In 2018, about 41.8% of Americans from this age group had private health coverage. More than half (54.7%) had private coverage. The latest health insurance statistics show that only 5.2% were uninsured.
(CDC)
20. The share of uninsured poor and near-poor Americans has significantly dropped since 2010.
In 2010, over 80% of adult Americans without health insurance were either poor or near-poor. Less than 15% of uninsured adults in 2010 weren’t poor. In 2018, in contrast, all these figures significantly dropped. So, only 27.4% and 25.1% of near-poor and poor adults had no health coverage. Health insurance facts further show that only 8.3% of not poor Americans were uninsured in 2018.
(CDC)
21. The percentage of Americans under 65 with private health insurance has improved over the past few years.
In 2018, about 4.4% of all citizens between 18-64 had private coverage. These consumers obtained their coverage either through a state-based exchange or via the Health Insurance Marketplace. In Q1 of 2014, in contrast, this share was below 2%. About 4.0% of Americans under 65 and 2.8% of those under 18 had private health coverage in 2018. Both these aspects improved since 2010 when the respective rates were 1.5% and 0.5%, according to US health insurance statistics.
(CDC)
22. Nearly 50% of persons under 65 were enrolled in a high-deductible health plan.
Approximately 45.8% of Americans under 65 had either a high-deductible health plan or a consumer-directed health plan in 2018. More precisely, 24.4% had an HDHP without a health savings account, and 20.4% had a CDHP.
(CDC)
23. Hispanic Americans record the highest rates of uninsured individuals.
About 26.7% of people from this race and ethnicity were uninsured in 2018, according to stats on health insurance demographics. This figure, however, had significantly dropped since 2010 when the share of uninsured Hispanics was over 40%. African Americans had the second-highest share of people without health insurance at 15.2%. Only 9.0% and 8.1% of Asian and White Americans didn’t have health insurance in 2018. These figures apply to American adults aged 18-64.
(CDC)
24. Most White Americans have private health coverage, while most Hispanics are enrolled in Medicaid.
About 69% of White Americans had private insurance, while 23.8% and 4.1% were in Medicaid or uninsured, respectively. Among African Americans, the shares of individuals with private coverage, in Medicaid, and uninsured were 36.3%, 56.1%, and 4%, respectively. Asians in the US mostly had private health coverage (70.8%), as suggested by health insurance enrolment statistics. Approximately 23.6% and 2.8% among those were enrolled in Medicaid or had no insurance. Finally, only 34.8% of Asians had private coverage, and 7.7% had no insurance. The majority (55.1%) were enrolled in Medicaid. These stats are for 2017 and apply to Americans under 18.
(CDC)
25. Most uninsured American adults have been uninsured for less than a year.
About 17.7% of the participants claimed to be uninsured for some part of the year. Approximately 13.3% said that they were uninsured at the time of the interview. Only 7.9% of the people were without health insurance for over a year, as indicated by the United States health insurance statistics. All these segments have improved compared to the figures recorded in 2010. Namely, the shares of uninsured people for some time and 12+ months were about 30% and 15%.
(CDC)
26. Texas has the largest percentage of adults aged 18-64 without health insurance.
In 2018, about 25% of Texas consumers had no health coverage, while a year before 26.4% were in the same situation. Other states high on this list are Georgia (20.9%), Florida (20%), and North Carolina (17.2%), as indicated by health insurance statistics by state. Ohio noted a serious jump in the share of the uninsured population from 9.4% in 2017 to 12.7% in 2018. Vivaldi armida. New Jersey had the opposite trend when the rate dropped from 11.8% in 2017 to 9.3% in 2018.
(CDC)
27. Nearly one-fourth of American adults aged 26-34 are uninsured.
About 22.4% of people from this age group had no health insurance in 2018. Next came Americans aged 35-44 with 20.2%. Around 16.3% of US consumers from the age group 45-54 were uninsured in 2018. The respective uninsured percentages of those aged 19-25, 0-18, and 55-64 in 2018 were 15.1%, 14%, and 12%. Elderly Americans weren’t included in these health insurance facts and stats.
(Statista)
28. Over 30 million Americans have no health insurance.
In 2018, a total of 30.4 million US citizens had no health coverage. This figure has been slowly progressing in the period between 2015-2018. It, however, is much lower than the nearly 50 million (48.6 million) uninsured people recorded in 2010. Last time this figure was over 40 million was in 2013 when 44.8 million Americans were uninsured.
(Statista)
29. Only 316,000 American adults making $75,000 have no health insurance.
These Statista figures were for 2010 when 11.8 million single adults were uninsured. Per the health insurance stats, 8.73 million of those made less than $25,000 a year. Meaning, most uninsured American adults belong to the lowest income group. People who were making between $25,000-49,999 represented about 2.32 million uninsured consumers. Finally, about 478,000 Americans earning from $50,000-74,999 a year had no health insurance in 2010.
(Statista)
30. Health insurance expenditures totaled $2.34 trillion in 2017.
The largest share from these expenditures was covered by private health insurance. Health insurance statistics show that the total health insurance premiums paid in the US by Medicare and Medicaid were $660 billion and $521 billion, respectively. Stats on healthcare costs by country show that the total US personal healthcare expenditures reached $2.71 trillion.
(CDC)
31. Healthcare fraud costs the US nearly $6 billion.
In the fiscal year 2019, the expected audit recoveries totaled $819 million, while the expected investigative recoveries were $5.04 billion. Investigators issued 163 audit reports and 46 evaluations. The amount of questioned costs was $913 billion, whereas the potential savings were $836 billion. In the fiscal year 2019, 809 criminal actions and 695 civil actions were opened, as evidenced by health insurance fraud statistics.
(HHS)
32. Healthcare.gov health insurance issuers deny, on average, 18% of all claims.
This percentage represents nearly 42 million claims. On average, 82% of all in-house claims are approved by such healthcare.gov issuers. This means that 190.9 million requests get the green light. Only 10 out of 130 reporting issuers from healthcare.gov had denial rates of over 30%, according to health insurance claim denial statistics.
Texas (26.60%), New Mexico (26.60%) Kentucky (25.10%), and Georgia (25.60%) are the states with the highest average rates of denied claims.
(Kaiser Family Foundation)
33. In 2008, the average denial rate was about 13%, and Americans aged 60-64 dealt with this issue the most.
About 29% of Americans from this age group had denied claims in 2008. Lower shares of about 35%, 20%, and 15% were recorded among those aged 55-59, 50-54, and 45-49. As the denial of health insurance claims statistics indicate, younger individuals have fewer such issues. Only 5% and 10% of Americans under 17 and 18-24 dealt with denied claims. The denial rates among those 25-39 went between 12% and 15%.
(GAO)
FAQs
What happens when you don’t have health insurance?
People without health insurance coverage in the United States must pay a fine when they submit their taxes. More importantly though, you may end up with huge medical bills if you’re treated for a severe injury or illness.
How big is the health insurance industry?
In 2018, the global health insurance market size was a stunning $1.4 trillion, according to Global Market Insights. By 2025, the sector is expected to surpass $1.5 trillion. The North American market share of the global health insurance industry in 2018 was over 33%.
How many health insurance companies exist in the US?
The total number of health insurance companies in the US surpassed 900. Health insurance companies offer various health coverage plans to millions of Americans and their employers. Top brands operating in the USA health insurance industry are UnitedHealth, Anthem, Humana, and CVS.
Can I live in one state and have health insurance in another?
Yes and no. You can’t have a single health coverage plan in one state and live in another. You can, however, have multiple health insurance plans in different states. Each state has its own regulations and, therefore, you must be insured by a company working under that jurisdiction.
Final Words
With the American medical costs being higher than ever, health coverage is the best investment one can make these days. Even though over 30 million US citizens are uninsured, the latest American health insurance statistics reveal positive trends. Plus, employers cover about 70% of the total cost of private health insurance in the US. If these positive changes continue, fewer people in the US will deal with medical bankruptcies and massive bills.
References: Statista, Statista, Statista, NAIC, Kaiser Family Foundation, Kaiser Family Foundation, Kaiser Family Foundation, Kaiser Family Foundation, CDC, CDC, CDC, Statista, Statista, Statista, CDC, HHS, Kaiser Family Foundation, GAO
2017 Employer Health Benefits Survey
Published: Sep 19, 2017
Section 9: Prescription Drug Benefits
Almost all covered workers have coverage for prescription drugs. Over the years that we have conducted the survey, coverage for prescriptions has become more complex as employers and insurers expanded the use of formularies with multiple cost-sharing tiers as well as other management approaches. Collecting information about these practices is challenging and was burdensome to respondents with multiple plans to report on.
Beginning in 2016, to reduce burden on respondents, we revised the survey to ask respondents about the attributes of prescription drug coverage only in their largest health plan; previously, we asked about prescription coverage in their largest plan for each of the plan types that they offered. After reviewing the responses and comparing them to prior years where we asked about each plan type, we find that the information we are receiving is quite similar to responses from previous years. For this reason, we will continue to report our results for these questions weighted by the number of covered workers in responding firms. There is a more detailed discussion in the survey design and methods section on this topic.
In addition, because of the significant policy interest in access to and the cost of specialty drugs, in 2016 we also began asking employers to report separately about the cost sharing for tiers that cover only specialty drugs. In cases in which a tier covers only specialty drugs, we report its attributes under the specialty banner, rather than as one of the standard tiers. This entails revising the way we group formulary tiers: for example, a three-tier formulary where the third tier covers exclusively specialty drugs is now consider a two-tier plan with an additional tier. This approach allows us to report on the cost sharing for specialty drugs regardless of the number of tiers in the formulary. For this reason, we are not presenting statistical comparisons of estimates relying on tiers to prior years.31 This change is also discussed more fully in the survey design and methods section.
- Nearly all (99%) covered workers work at a firm that provides prescription drug coverage in their largest health plan.
DISTRIBUTION OF COST-SHARING
- A large share of covered workers (91%) are in a plan with a tiered cost-sharing formula for prescription drugs [Figure 9.1]. Cost-sharing tiers generally refer to a health plan placing a drug on a formulary or preferred drug list that classifies drugs into categories that are subject to different cost sharing or management. It is common for there to be different tiers for generic, preferred and non-preferred drugs. In recent years, plans have created additional tiers which, for example, may be used for lifestyle drugs or expensive biologics. Some plans may have multiple tiers for different categories; for example, a plan may have preferred and non-preferred specialty tiers. The survey obtains information about the cost-sharing structure for up to five tiers.
- Eighty-three percent of covered workers are in a plan with three, four, or more tiers of cost sharing for prescription drugs [Figure 9.1]. These totals include tiers that cover only specialty drugs, even though the cost-sharing information for those tiers is reported separately.
- HDHP/SOs have a different cost-sharing pattern for prescription drugs than other plan types. Covered workers in HDHP/SOs are more likely to be in a plan with the same cost sharing regardless of drug type (15% vs. 2%) or in a plan that has no cost sharing for prescriptions once the plan deductible is met (13% vs. <1%) as compared to covered workers in other types of plans [Figure 9.2].
Figure 9.1: Distribution of Covered Workers Facing Different Cost-Sharing Formulas for Prescription Drug Benefits, by Firm Size, 2017
Figure 9.2: Distribution of Covered Workers Facing Different Cost-Sharing Formulas for Prescription Drug Benefits, by Plan Type, 2017
AVERAGE COST-SHARING NOT INCLUDING TIERS EXCLUSIVELY COVERING SPECIALTY DRUGS
- Even when formulary tiers covering only specialty drugs are not included, a large share (77%) of covered workers are in a plan with three or more tiers of cost sharing for prescription drugs. The cost-sharing statistics presented in this section do not include information about tiers that cover only specialty drugs. In cases in which a plan covers specialty drugs on a tier with other drugs, they will still be included in these averages. Cost-sharing statistics for tiers covering only specialty drugs are presented in the next section.
- For covered workers in a plan with three or more tiers of cost sharing for prescription drugs, copayments are the most common form of cost sharing in the first three tiers and coinsurance is the next most common. Among those with a fourth tier, the difference between the percentage with a copayment and a coinsurance requirement is not statistically significant [Figure 9.3].
- Among covered workers in plans with three or more tiers of cost sharing for prescription drugs, the average copayments are $11 for first-tier drugs, $33 second-tier drugs, $59 for third-tier drugs, and $110 for fourth-tier drugs [Figure 9.6].
- Among covered workers in plans with three or more tiers of cost sharing for prescription drugs, the average coinsurance rates are 17% for first-tier drugs, 25% second-tier drugs, 38% third-tier drugs, and 28% for fourth-tier drugs [Figure 9.6].
- Eleven percent of covered workers are in a plan with two tiers for prescription drug cost sharing (excluding tiers covering only specialty drugs).
- For these workers, copayments are more common than coinsurance for both first-tier and second-tier drugs. The average copayment for the first tier is $11 and the average copayment for the second tier is $30 [Figure 9.3].
- Seven percent of covered workers are in a plan with the same cost sharing for prescriptions regardless of the type of drug (excluding tiers covering only specialty drugs).
- Among these workers, 21% have copayments and 79% have coinsurance [Figure 9.3]. The average coinsurance rate is 19% and the average copayment is $11 [Figure 9.7].
- Twenty-one percent of these workers are in a plan that limits coverage for prescriptions to generic drugs [Figure 9.9].
- Coinsurance rates for prescription drugs often have maximum and/or minimum dollar amounts associated with the coinsurance rate. Depending on the plan design, coinsurance maximums may significantly limit the amount an enrollee must spend out-of-pocket for higher cost drugs.
- These coinsurance minimum and maximum amounts vary across the tiers.
- For example, among covered workers in a plan with coinsurance for the first cost-sharing tier, 25% have only a maximum dollar amount attached to the coinsurance rate, 8% have only a minimum dollar amount, 18% have both a minimum and maximum dollar amount, and 49% have neither. For those in a plan with coinsurance for the fourth cost-sharing tier, 52% have only a maximum dollar amount attached to the coinsurance rate, 4% have only a minimum dollar amount, 12% have both a minimum and maximum dollar amount, and 33% have neither. [Figure 9.8].
Figure 9.3: Among Workers With Prescription Drug Coverage, Distribution of Covered Workers With the Following Types of Cost Sharing for Prescription Drugs, 2017
Figure 9.4: Among Workers With Three or More Tiers of Cost Sharing, Distribution of Covered Workers With the Following Types of Cost Sharing for Prescription Drugs, by Firm Size, 2017
Figure 9.5: Among Covered Workers With Three or More Tiers of Prescription Cost Sharing, Distribution of Covered Workers With the Following Types of Cost Sharing for Prescription Drugs, by Plan Type, 2017
Figure 9.6: Among Covered Workers With Three or More Tiers of Prescription Drug Cost Sharing, Average Copayments and Coinsurance, 2017
Figure 9.7: Among Covered Workers With Prescription Drug Coverage, Average Copayments and Coinsurance, 2017
Figure 9.8: Distribution of Coinsurance Structures for Covered Workers Facing a Coinsurance for Prescription Drugs, 2017
Figure 9.9: Among Covered Workers With Prescription Drug Coverage, Coverage of Generic Drugs by Plan Design, 2017
SPECIALTY DRUGS
- Specialty drugs, such as biologics that may be used to treat chronic conditions or some cancer drugs, can be quite expensive and often require special handling and administration. We revised our questions beginning with the 2016 survey to obtain more information about formulary tiers that are exclusively for specialty drugs. We are reporting results only among large firms because a substantial share of small firms were unsure whether their largest plan covered these drugs.
- Ninety-seven percent of covered workers at large firms have coverage for specialty drugs [Figure 9.10]. Among these workers, 47% are in a plan with at least one cost-sharing tier just for specialty drugs [Figure 9.11].
- Among covered workers in a plan with a separate tier for specialty drugs, 45% have a copayment for specialty drugs and 46% have a coinsurance [Figure 9.12]. The average copayment is $101 and the average coinsurance rate is 27% [Figure 9.13]. Eighty percent of those with a coinsurance have a maximum dollar limit on the amount of coinsurance they must pay.
- Some covered workers are also required to meet a deductible before the plan covers specialty drugs. Among covered workers enrolled in a plan with a deductible and specialty drug coverage, 29% must meet the general annual deductible and 15% must meet a separate drug deductible before specialty drugs are covered [Figure 9.14].
Figure 9.10: Among Large Firms Whose Prescription Drug Coverage Includes Specialty Drugs, Percentage of Covered Workers Whose Plan With the Largest Enrollment Includes Coverage for Specialty Drugs, by Firm Size, 2017
Average Copay For Health Insurance Per
Figure 9.11: Among Large Firms Whose Prescription Drug Coverage Includes Specialty Drugs, Percentage of Covered Workers Enrolled in a Plan That Has a Separate Ties for Specialty Drugs, by Firm Size, 2017
Figure 9.12: Among Covered Works at Large Firms Enrolled in a Plan with a Separate Tier for Specialty Drugs, Distribution of Covered Works with the Following Types of Cost Charing, by Firm Size, 2017
Figure 9.13: Among Covered Workers at Large Firms Enrolled In a Plan With a Separate Tier for Specialty Drugs, Average Copayments and Coinsurance, by Firm Size, 2017
Figure 9.14: Among Covered Workers Enrolled In a Plan With a Deductible and Specialty Drug Coverage, Percentage Enrolled In a Plan With Specialty Drugs Subject to a Deductible, by Firm Size, 2017
Average Copay For Health Insurance
SEPARATE ANNUAL DRUG DEDUCTIBLES
- In addition to other cost sharing, some covered workers are also required to meet a separate prescription drug deductible before the plan covers some or all drugs. Fifteen percent of covered workers are in a plan with a separate annual deductible for prescription drugs [Figure 9.15]. These prescription drug deductibles are separate from any general annual deductible and may apply to all or a select number of tiers.
- For 57% of covered workers in firms with a separate deductible for prescription drugs, the deductible applies to all drugs on each of the formulary tiers [Figure 9.16].
- The average annual deductible among covered workers in firms who face a separate annual deductible is $149 [Figure 9.16].
Figure 9.15: Among Covered Workers with a General Annual Deductible, Percentage of Workers with a Separat Annual Deductible That Applies Only to Prescription Drugs, by Firm Size, 2005-2017
Figure 9.16: Percentage of Covered Workers with Drug Coverage Who Face a Separate Drug Deductible and Value of Drug Deductible, by Firm Size, 2017
- Generic drugs
- Drugs that are no longer covered by patent protection and thus may be produced and/or distributed by multiple drug companies.
- Preferred drugs
- Drugs included on a formulary or preferred drug list; for example, a brand-name drug without a generic substitute.
- Non-preferred drugs
- Drugs not included on a formulary or preferred drug list; for example, a brand-name drug with a generic substitute.
- Fourth-tier drugs
- New types of cost-sharing arrangements that typically build additional layers of higher copayments or coinsurance for specifically identified types of drugs, such as lifestyle drugs or biologics.
- Specialty drugs
- Specialty drugs such as biological drugs are high cost drugs that may be used to treat chronic conditions such as blood disorder, arthritis or cancer. Often times they require special handling and may be administered through injection or infusion.
- See the Methods Section for more information. In cases in which a firm indicated that one of their tiers was exclusively for specialty drugs, we reported the cost-sharing structure and any copay or coinsurance information under the specialty drug banner. Therefore, a firm that has three tiers of cost sharing may only have plan attributes for the generic and preferred tiers.↩