INSURER-PHARMACY BENEFIT MANAGER VERTICAL INTEGRATION AND PATIENT OUT-OF-POCKET SPENDING
Author(s)
Yang Wang, PhD;
Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
OBJECTIVES: The growing vertical integration between insurance carriers and pharmacy benefit managers (PBMs) raises concerns on competition, access, and affordability of prescription drugs. Prior research found this vertical integration has led to increased premiums for rival insurance plans in Medicare market. This study examines if the insurer-PBM vertical integration is associated with increased patient Out-of-Pocket (OOP) spending for medications.
METHODS: Leveraging 2024 national pharmacy claims data, this study focused on the Medicare Part D program, including standalone plans (PDP), Medicare Advantage plans (MA-PD), and special needs plans (SNP) that contracted with the 5 major PBMs (Express Scripts, CVS, Optum, Prime Therapeutics, Carelon Rx). Within each PBM, vertically integrated (VI) plans were identified if the corresponding insurer was the parent company of that PBM, and non-VI plans for other insurers. Main outcome was patient’s OOP payment per branded drug claim. Generalized linear models were performed to estimate the relationship between VI status and patient OOP amount, adjusting for refill status, days of supply, service quarter, patient characteristics, and PBM and molecule fixed effects.
RESULTS: Study sample included 2,470,563 paid claims from 376,517 Medicare patients, 794 plans, and 102 drug molecules. VI plans accounted for 64% of all paid claims (63% in PDP; 56% in MA-PD; 90% in SNP). VI plans had higher patient OOP payments in PDP market (mean $81 vs $48), followed by MA-PD ($48 vs $43), and SNP ($0 vs $1). Regression found VI status was associated with 48% (95% CI 46% - 50%), 1% (95% CI -1% - 2%), and 0% (95% CI -2% - 2%) higher OOP payment for PDP, MA, and SNP plans, respectively.
CONCLUSIONS: Patients covered by VI plans in Medicare PDP market faced higher OOP payments for branded drugs, suggesting less generous benefits.
METHODS: Leveraging 2024 national pharmacy claims data, this study focused on the Medicare Part D program, including standalone plans (PDP), Medicare Advantage plans (MA-PD), and special needs plans (SNP) that contracted with the 5 major PBMs (Express Scripts, CVS, Optum, Prime Therapeutics, Carelon Rx). Within each PBM, vertically integrated (VI) plans were identified if the corresponding insurer was the parent company of that PBM, and non-VI plans for other insurers. Main outcome was patient’s OOP payment per branded drug claim. Generalized linear models were performed to estimate the relationship between VI status and patient OOP amount, adjusting for refill status, days of supply, service quarter, patient characteristics, and PBM and molecule fixed effects.
RESULTS: Study sample included 2,470,563 paid claims from 376,517 Medicare patients, 794 plans, and 102 drug molecules. VI plans accounted for 64% of all paid claims (63% in PDP; 56% in MA-PD; 90% in SNP). VI plans had higher patient OOP payments in PDP market (mean $81 vs $48), followed by MA-PD ($48 vs $43), and SNP ($0 vs $1). Regression found VI status was associated with 48% (95% CI 46% - 50%), 1% (95% CI -1% - 2%), and 0% (95% CI -2% - 2%) higher OOP payment for PDP, MA, and SNP plans, respectively.
CONCLUSIONS: Patients covered by VI plans in Medicare PDP market faced higher OOP payments for branded drugs, suggesting less generous benefits.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR33
Topic
Health Policy & Regulatory
Topic Subcategory
Pricing Policy & Schemes, Reimbursement & Access Policy, Risk-sharing Approaches
Disease
No Additional Disease & Conditions/Specialized Treatment Areas