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Industry: Email Alert RSS FeedMedicare+Choice: diminished Rx benefits, dwindling membership - Brief Article
Drug Cost Management Report, April, 2003
Figure 1. 25 Largest Medicare Plans and Their Drug Copay Structures
Medicare
Medicare HMO Enrollment(a)
Kaiser Foundation Health Plan, 621,919
Inc. - Los Angeles (Kaiser
Permanente Senior Advantage)
PacifiCare of California, Inc. - 388,705
Southern California (Secure
Horizons)
Humana Medical Plan, Inc. - 228,752
South Florida Market
(Humana Gold Plus Plan)
Keystone Health Plan 189,634
West, Inc. (Security Blue)
Keystone Health Plan 141,905
East, Inc. (Keystone 65)
Health Net of California 102,132
(Seniority Plus)
PacifiCare of Texas, Inc. - 101,258
San Antonio (Secure Horizons)
HIP of Greater New York 100,159
(HIP VIP Medicare Plan)
Tufts Associated HMO, Inc. 92,226
(Secure Horizons/Tufts Health
Plan for Seniors)
PacifiCare of Arizona, Inc. 88,722
(Secure Horizons)
Community Insurance Company 83,265
(Anthem Senior Advantage)
Oxford Health Plans, Inc. - 67,362
New York (Oxford Medicare
Advantage)
California Physicians' 66,988
Services Corp. - Los Angeles Basin
(Shield 65)
Health Options, Inc. - 64,240
South Florida (Medicare and More)
Horizon Healthcare of 62,010
New Jersey, Inc. (Medicare Blue)
Group Health Cooperative of 60,140
Puget Sound (Group Health
Medicare)
UnitedHealthcare of the 58,879
Midwest, Inc. (Medicare Complete)
Blue Cross of California 58,118
(Blue Cross Senior Secure)
Humana Health Care Plan, Inc. 57,637
(Humana Gold Plus Plan)
-Illinois
Kaiser Foundation Health 56,318
Plan of Colorado, Inc. (Kaiser
Permanente Senior Advantage)
PacifiCare of Washington, Inc. 55,761
(Secure Horizons)
Empire HealthChoice HMO, Inc. 55,459
(BlueChoice Senior Plan)
Scan Health Plan (SCAN) 55,092
PacifiCare of Colorado, Inc. 53,436
(Secure Horizons)
Kaiser Foundation Health Plan 43,628
of the Northwest (Kaiser NW)
Medicare HMO PBM Vendor(b)
Kaiser Foundation Health Plan, NA
Inc. - Los Angeles (Kaiser
Permanente Senior Advantage)
PacifiCare of California, Inc. - Prescription Solutions, Inc.
Southern California (Secure
Horizons)
Humana Medical Plan, Inc. - AdvancePCS
South Florida Market
(Humana Gold Plus Plan)
Keystone Health Plan Medco Health Solutions, Inc.
West, Inc. (Security Blue)
Keystone Health Plan Medco Health Solutions, Inc.
East, Inc. (Keystone 65)
Health Net of California AdvancePCS; Health Net
(Seniority Plus) Pharmaceutical Services
PacifiCare of Texas, Inc. - Prescription Solutions, Inc.
San Antonio (Secure Horizons)
HIP of Greater New York Express Scripts, Inc.
(HIP VIP Medicare Plan) (mail-order only)
Tufts Associated HMO, Inc. AdvancePCS, Express
(Secure Horizons/Tufts Health Scripts, Inc.
Plan for Seniors)
PacifiCare of Arizona, Inc. Prescription Solutions, Inc.
(Secure Horizons)
Community Insurance Company Anthem Prescription Management,
(Anthem Senior Advantage) LLC
Oxford Health Plans, Inc. - Medco Health Solutions, Inc.
New York (Oxford Medicare
Advantage)
California Physicians' Internal; Mail: Express
Services Corp. - Los Angeles Basin Scripts, Inc.
(Shield 65)
Health Options, Inc. - Medco Health Solutions, Inc.
South Florida (Medicare and More)
Horizon Healthcare of AdvancePCS
New Jersey, Inc. (Medicare Blue)
Group Health Cooperative of MedImpact, Inc.
Puget Sound (Group Health
Medicare)
UnitedHealthcare of the Medco Health Solutions, Inc.
Midwest, Inc. (Medicare Complete)
Blue Cross of California WellPoint Pharmacy
(Blue Cross Senior Secure) Management, Inc.
Humana Health Care Plan, Inc. AdvancePCS
(Humana Gold Plus Plan)
-Illinois
Kaiser Foundation Health NA
Plan of Colorado, Inc. (Kaiser
Permanente Senior Advantage)
PacifiCare of Washington, Inc. Prescription Solutions, Inc.
(Secure Horizons)
Empire HealthChoice HMO, Inc. AdvancePCS
(BlueChoice Senior Plan)
Scan Health Plan (SCAN) NA
PacifiCare of Colorado, Inc. Prescription Solutions, Inc.
(Secure Horizons)
Kaiser Foundation Health Plan NA
of the Northwest (Kaiser NW)
Rx Copay Structure Offered-
One Month Supply
Medicare HMO Generic
Kaiser Foundation Health Plan, * $10.00
Inc. - Los Angeles (Kaiser
Permanente Senior Advantage)
PacifiCare of California, Inc. - $9.00
Southern California (Secure $9.00
Horizons)
Humana Medical Plan, Inc. - $0.00
South Florida Market $0.00
(Humana Gold Plus Plan) $0.00
$10.00
$15.00
$22.50
Keystone Health Plan $12.00
West, Inc. (Security Blue)
Keystone Health Plan $15.00
East, Inc. (Keystone 65) $15.00
Health Net of California $10.00
(Seniority Plus) $10.00
PacifiCare of Texas, Inc. - $10.00
San Antonio (Secure Horizons) $15.00
HIP of Greater New York $10.00
(HIP VIP Medicare Plan) $10.00
Tufts Associated HMO, Inc. $10.00
(Secure Horizons/Tufts Health
Plan for Seniors)
PacifiCare of Arizona, Inc. $15.00
(Secure Horizons)
Community Insurance Company $15.00
(Anthem Senior Advantage)
Oxford Health Plans, Inc. - 50%
New York (Oxford Medicare
Advantage) 50%
California Physicians' $10.00
Services Corp. - Los Angeles Basin $10.00
(Shield 65) $10.00
Health Options, Inc. - No Rx
South Florida (Medicare and More) Benefit
Horizon Healthcare of No Rx
New Jersey, Inc. (Medicare Blue) Benefit
Group Health Cooperative of $15.00
Puget Sound (Group Health
Medicare)
UnitedHealthcare of the $12.00
Midwest, Inc. (Medicare Complete) $10.00
Blue Cross of California $8.00
(Blue Cross Senior Secure)
Humana Health Care Plan, Inc. $10.00
(Humana Gold Plus Plan) $15.00
-Illinois
Kaiser Foundation Health ** $10.0-
Plan of Colorado, Inc. (Kaiser
Permanente Senior Advantage) 0
PacifiCare of Washington, Inc. No Rx
(Secure Horizons) Benefit
Empire HealthChoice HMO, Inc. $10.00
(BlueChoice Senior Plan) $10.00
Scan Health Plan (SCAN) $10.00
PacifiCare of Colorado, Inc. $12.00
(Secure Horizons) $15.00
Kaiser Foundation Health Plan 70%
of the Northwest (Kaiser NW)
Rx Copay Structure Offered-
One Month Supply
Preferred
Medicare HMO Brand
Kaiser Foundation Health Plan, NA
Inc. - Los Angeles (Kaiser
Permanente Senior Advantage)
PacifiCare of California, Inc. - NA
Southern California (Secure NA
Horizons)
Humana Medical Plan, Inc. - NA
South Florida Market NA
(Humana Gold Plus Plan) NA
NA
NA
NA
Keystone Health Plan $20.00
West, Inc. (Security Blue)
Keystone Health Plan NA
East, Inc. (Keystone 65) NA
Health Net of California NA
(Seniority Plus) NA
PacifiCare of Texas, Inc. - NA
San Antonio (Secure Horizons) NA
HIP of Greater New York NA
(HIP VIP Medicare Plan) NA
Tufts Associated HMO, Inc. $20.00
(Secure Horizons/Tufts Health
Plan for Seniors)
PacifiCare of Arizona, Inc. NA
(Secure Horizons)
Community Insurance Company NA
(Anthem Senior Advantage)
Oxford Health Plans, Inc. - NA
New York (Oxford Medicare
Advantage) NA
California Physicians' NA
Services Corp. - Los Angeles Basin NA
(Shield 65) NA
Health Options, Inc. - No Rx
South Florida (Medicare and More) Benefit
Horizon Healthcare of No Rx
New Jersey, Inc. (Medicare Blue) Benefit
Group Health Cooperative of $15.00
Puget Sound (Group Health
Medicare)
UnitedHealthcare of the NA
Midwest, Inc. (Medicare Complete) NA
Blue Cross of California NA
(Blue Cross Senior Secure)
Humana Health Care Plan, Inc. NA
(Humana Gold Plus Plan) NA
-Illinois
Kaiser Foundation Health NA
Plan of Colorado, Inc. (Kaiser
Permanente Senior Advantage)
PacifiCare of Washington, Inc. No Rx
(Secure Horizons) Benefit
Empire HealthChoice HMO, Inc. $25.00
(BlueChoice Senior Plan) NA
Scan Health Plan (SCAN) $30.00
PacifiCare of Colorado, Inc. NA
(Secure Horizons) NA
Kaiser Foundation Health Plan NA
of the Northwest (Kaiser NW)
Rx Copay Structure Offered-
One Month Supply
Medicare HMO Brand
Kaiser Foundation Health Plan, * $30.00
Inc. - Los Angeles (Kaiser
Permanente Senior Advantage)
PacifiCare of California, Inc. - $30.00
Southern California (Secure NA
Horizons)
Humana Medical Plan, Inc. - $15.00
South Florida Market $20.00
(Humana Gold Plus Plan) $37.50
NA
NA
NA
Keystone Health Plan $30.00
West, Inc. (Security Blue)
Keystone Health Plan $20.00
East, Inc. (Keystone 65) NA
Health Net of California 50%
(Seniority Plus) NA
PacifiCare of Texas, Inc. - $30.00
San Antonio (Secure Horizons) NA
HIP of Greater New York $20.00
(HIP VIP Medicare Plan) NA
Tufts Associated HMO, Inc. $40.00
(Secure Horizons/Tufts Health
Plan for Seniors)
PacifiCare of Arizona, Inc. NA
(Secure Horizons)
Community Insurance Company $40.00
(Anthem Senior Advantage)
Oxford Health Plans, Inc. - 50%
New York (Oxford Medicare
Advantage) NA
California Physicians' $25.00
Services Corp. - Los Angeles Basin $35.00
(Shield 65) NA
Health Options, Inc. - No Rx
South Florida (Medicare and More) Benefit
Horizon Healthcare of No Rx
New Jersey, Inc. (Medicare Blue) Benefit
Group Health Cooperative of $15.00
Puget Sound (Group Health
Medicare)
UnitedHealthcare of the NA
Midwest, Inc. (Medicare Complete) $60.00
Blue Cross of California NA
(Blue Cross Senior Secure)
Humana Health Care Plan, Inc. $35.00
(Humana Gold Plus Plan) NA
-Illinois
Kaiser Foundation Health ** $50.-
Plan of Colorado, Inc. (Kaiser
Permanente Senior Advantage) 00
PacifiCare of Washington, Inc. No Rx
(Secure Horizons) Benefit
Empire HealthChoice HMO, Inc. $45.00
(BlueChoice Senior Plan) NA
Scan Health Plan (SCAN) $75.00
PacifiCare of Colorado, Inc. $45.00
(Secure Horizons) $45.00
Kaiser Foundation Health Plan 70%
of the Northwest (Kaiser NW)
(a) 2002 year-end enrollment. (b) PBM company(les) with which the
MCO contracts; vendor relationships may or may not cover Medicare Rx
benefit lives. * 3-month supply; ** 2-month supply, NA=not applicable.
SOURCES: "Managed Medicare and Medicaid Factbook: 2003,"
and "AIS's HMO Directory: 2003." For more information,
call (800)-521-4323.
Figure 2. Average Medicare Drug Copay,
by Tier, 2001-2003
Average Copay 2001 2002 2003
1st Tier $8.96 $8.54 $9.53
2nd Tier $18.48 $20.81 $22.70
3rd Tier $25.74 $30.81 $39.23
Note: Table made from bar graph.
Figure 3. Tiered Rx Copay Differentials
Among Medicare Plans, 2001-2003
Average Copay Differential
2001 2002 2003
Average 1st-2nd Tier Copay
Differential $9.52 $12.27 $13.17
Average 2nd-3rd Tier Copay
Differential $7.26 $10.00 $16.53
Note: Table made from bar graph.
Figure 4. Average Copays and
Differentials for Medicare Plans vs.
Overall Rx Plans Offered by PBMs
Copay
1st 2nd 3rd
Tier Tier Tier
Average of all Rx plans $9.53 $22.70 $39.23
offered by Medicare
plans.
Average of all Rx plans $7.52 $17.62 $30.80
offered by PBMs *
Difference $2.01 $5.08 $8.43
Copay Differentials
1st-2nd 2nd-3rd
Tier Tier
Average of all Rx plans $13.17 $16.53
offered by Medicare
plans.
Average of all Rx plans $10.10 $13.18
offered by PBMs *
Difference $3.07 $3.35
* Including commercial, Medicare and Medicaid plans.
Figure 5. Average One-Month Retail Rx
Copay for Medicare Plans, by CMS
Region
CMS Region Generic Preferred Brand
Brand
Region 1: New England $9.39 $17.31 $27.94
Region 2: Eastern $10.46 $26.67 $26.67
Region 3: Mid-Atlantic $12.11 $20.00 $33.53
Region 4: Southeast $10.20 NA $30.44
Region 5: Midwest $11.40 $22.14 $31.17
Region 6: Southwest $13.00 $26.67 $25.71
Region 7: Central Plains $14.42 NA $44.00
Region 8: Rocky Mountain $15.86 $39.17 $52.00
Region 9: West Coast $10.04 $29.25 $43.23
Region 10: Northwest $12.50 $15.00 $20.00
NA=Tier definition is not applicable to any plans in that region.
Note: Table made from bar graph.
Figure 6. Percentage Change in Medicare
Rx Copay Per 30-Day Supply at Retail,
2002-2003, by CMS Region
Preferred
Generic Brand Brand
Region 1: New England 19% 15% 22%
Region 2: Eastern 10% 33% 27%
Region 3: Mid-Atlantic 6% 7% 22%
Region 4: Southeast 49% -10% 14%
Region 5: Midwest 26% -11% 10%
Region 6: Southwest 22% -20% -4%
Region 7: Central Plains 22% NA 14%
Region 8: Rocky Mountain 59% NA 160%
Region 9: West Coast 10% 28% 43%
Region 10: Northwest 25% NA 33%
NA=Tier definition is not applicable to any plans in that region.
Figure 7. Average Three-Month Mail-Order
Rx Copay for Medicare Plans, by
CMS Region
CMS Region Average Rx Copay
Generic Preferred Brand
Brand
Region 1: New England $18.22 $30.91 $50.67
Region 2: Eastern $22.00 $50.00 $30.83
Region 3: Mid-Atlantic $24.23 $40.00 $65.00
Region 4: Southeast $29.13 NA $62.47
Region 5: Midwest $30.19 $45.40 $67.85
Region 6: Southwest $33.76 $83.33 $54.29
Region 7: Central Plains $39.75 NA $113.33
Region 8: Rocky Mountain $31.71 $78.33 $103.00
Region 9: West Coast $20.82 $59.33 $80.87
Region 10: Northwest $20.00 NA $50.00
NA=Tier definition is not applicable to any plans in that region.
Note: Table made from bar graph.
Figure 8. Percentage Change in Medicare
Rx Copay Per Three-Month Supply at Mail
Order, 2002-2003, by CMS Region
Preferred
CMS Region Generic Brand Brand
Region 1: New England 36% 3% 49%
Region 2: Eastern 21% NA 25%
Region 3: Mid-Atlantic 11% 0% 49%
Region 4: Southeast 65% 43% 25%
Region 5: Midwest 36% 39% 7%
Region 6: Southwest 49% 67% 20%
Region 7: Central Plains 51% NA 54%
Region 8: Rocky Mountain NA NA NA
Region 9: West Coast 7% 6% 33%
Region 10: Northwest 0% NA 25%
NA=Tier definition is not applicable to any plans in that region.
Figure 9. Mail-Order Savings Available to
Medicare Members With Rx Coverage, by
CMS Region
Preferred
CMS Region Generic Brand Brand
Region 1: New England $9.95 $21.01 $33.16
Region 2: Eastern $9.39 $30.00 $49.17
Region 3: Mid-Atlantic $12.10 $20.00 $35.59
Region 4: Southeast $1.05 ($12.49) $28.86
Region 5: Midwest $4.01 $21.03 $25.68
Region 6: Southwest $5.24 ($3.33) $22.86
Region 7: Central Plains $3.50 NA $18.67
Region 8: Rocky Mountain $15.86 $39.17 $53.00
Region 9: West Coast $9.29 $28.42 $48.81
Region 10: Northwest $17.50 NA $10.00
NA=Tier definition is not applicable to any plans in that region.
Figure 10. Percentage of Medicare
Plans Offering One-, Two- and Three-Tier
Rx Copay Options, 2002-2003
Percent of Medicare
Plans Offering
2002 2003
Generic-Only 25.71% 57.39%
2-Tier Copay 51.43% 26.09%
3-Tier Copay 22.86% 16.52%
Note: Table made from bar graph.
Figure 11. Average Additional Premium
Changes by Region, 2002-2003
CMS Region 2002 2003 Change
Region 1: New England $88.94 $105.71 $16.77
Region 2: Eastern $49.79 $98.19 $48.40
Region 3: Mid-Atlantic $74.83 $103.33 $28.50
Region 4: Southeast $17.60 $58.21 $40.61
Region 5: Midwest $63.09 $74.11 $11.02
Region 6: Southwest $26.07 $58.30 $32.23
Region 7: Central Plains $65.35 $53.00 -$12.35
Region 8: Rocky Mountain $99.00 $68.21 -$30.79
Region 9: West Coast $34.77 $38.04 $3.27
Region 10: Northwest $151.22 $176.67 $25.45
Figure 12. Average Premiums Charged
by Medicare HMOs With Rx Coverage,
by CMS Region
Average Regional Average Additional
Premium With Premium
Medicare Part B
Region 1: New England $164.41 $105.71
Region 2: Eastern $156.89 $98.19
Region 3: Mid-Atlantic $162.03 $103.33
Region 4: Southeast $116.91 $58.21
Region 5: Midwest $132.81 $74.11
Region 6: Southwest $117.00 $58.30
Region 7: Central Plains $111.70 $53.00
Region 8: Rocky Mountain $126.91 $68.21
Region 9: West Coast $96.74 $38.04
Region 10: Northwest $235.37 $176.67
Note: Table made from bar graph.
Figure 13. Maximum Rx Benefit Limits for
Medicare Plans, Structure and Average
Benefit Amounts
Average Number of
Limit Plans With
Limit Type Amount Type of Limit
Monthly Formulary Generic $40.00 5
Brand $50.00 1
Combined * $138.89 9
Non-Formulary Generic $50.00 1
Brand $50.00 1
Combined * Generic $100.00 4
Brand $212.50 4
Combined * $121.88 8
Quarterly Formulary Generic $112.50 2
Brand $150.00 15
Combined * $219.02 46
Combined * Brand $150.00 1
Combined * $263.33 15
Semi- Formulary Generic $500.00 1
Annual Brand $525.00 2
Non-Formulary Brand $525.00 2
Combined * Brand $250.00 1
Combined * $425.00 4
Annual Formulary Generic $729.58 71
Brand $830.77 13
Combined * $961.25 40
Combined * Generic $1,250.00 4
Brand $750.00 2
Combined * $653.57 14
* There are various combinations of formulary, non-formulary, generic,
brand and total benefit limits for different plans.
Figure 14. Five Medicare Plans With the
Lowest Annual Generic Benefit Limits
Annual Generic
Plan Plan Location Benefit Cap
UnitedHealthcare, Inc. Florida: Pasco, $200.00
Medicare Complete) Hernando counties
Mercy Health Plans of St. Louis metro area. $250.00
Missouri, Inc. (Premier Plus)
Mercy Health Plans of St. Louis metro area - $250.00
Missouri, Inc. (Premier Plus) Illinois.
UnitedHealthcare, Inc. Missouri: St. Louis $300.00
Medicare Complete)
UnitedHealthcare, Inc. Alabama: Blount, $300.00
Medicare Complete) Chilton, Jefferson, St.
Clair, Shelby counties.
COPYRIGHT 2003 Atlantic Information Services, Inc.
COPYRIGHT 2003 Gale Group
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