Analyzing the Value of Retail-30 vs Retail-90 Benefit Design Strategies

Dispensing a 90-day supply of medications has become a common benefit design in prescription drug programs today. Proponents tout lower costs and better clinical outcomes, but is that universally true? The answer: Not true! The financial and clinical value is not consistent for every pharmacy benefit plan. 

Any perceived improvement in clinical or economic value should be weighed against considerations for overuse, misuse, abuse, and pharmaceutical waste. Obviously, the average day supply on hand is much higher with Retail-90 claims. Therefore, changes in therapy and/or refilling too frequently can increase cost while promoting stockpiling and waste. The relative economic impact depends on the medication dispensed.

Here are some additional details that our clinical team’s analysis revealed about Retail-30 and Retail-90 prescription drug fills.

Defining Retail-30 and Retail-90

Retail-30 is a traditional benefit design feature that allows members only to procure both brand or generic medications in no more than 30 day-supply increments per dispensing. The site of dispensing occurs in the traditional pharmacy setting including chain, independent, or grocery chain pharmacy. Through Retail-30, there is a potential of 30 Day-Supply dispenses per year, as refills can occur when a member utilizes 75%-80% of their previously dispensed medication.

Retail-90 is a benefit design feature that allows members to procure brand and generic maintenance medications in up to 90 day-supply increments per dispensing within a traditional pharmacy setting. Often, the traditional pharmacy setting is restricted to a specific subset of pharmacies, dependent on the plan sponsor’s intent. The stated goal of Retail-90 is to improve the adherence of members to their maintenance medication by supplying them with a greater quantity. Retail-90 may have different options or restrictions, as well as different member cost-share arrangements as elected by the plan sponsor. Through Retail-90, there is a potential of 90-day supply dispenses per year, as refills can occur when a member utilizes 75%-80% of their previously dispensed medication.

Proponents of 90-day Rx dispensing tout lower costs and better clinical outcomes, but multiple factors play into the calculation of determining the actual value of this strategy for employer-sponsored pharmacy plans.

Bradley Nelson, PharmD, CSMC

Tweet Share

Comparing the Value of Retail-30 vs Retail-90

When discussing the pharmacy benefit plan cost on non-specialty medications, there are multiple factors to be considered: discounts, rebates, and copays.

• A quick and easy calculation of retail brand claims using an average Average Wholesale Price (AWP), discount, copays for Retail-30 and Retail-90, and guaranteed rebates can illustrate if there is economic value and what that value is.
• While discounts are typically higher with Retail-90 brand prescriptions, brand rebates are only 2.25 – 2.85 times the average Retail-30 brand claim rebate, which minimizes the plan sponsor’s rebate yield.
• The rebate yield is a measure of how well rebates work for a plan to bring about the lowest net cost of medication. For example, Retail-30 brand claims have better value for a plan than Retail-90 brand claim.
• Additionally, copays can vary widely depending on plan design, but they tend to favor the member and increase plan cost incrementally – usually by a multiple of the value of a single Retail-30 claim copayment for both brand and generic drugs.

With respect to the clinical value of Retail-30 vs Retail-90, adherence is often mentioned, but adherence is only a surrogate measure for compliance. Compliance (e.g., confirming consumption of a medication) cannot directly be measured through adherence programs (e.g., presumed, but not confirmed receipt of a medication). Retail-90 benefit designs improve the medication possession ratio, which conventional industry belief states translates into better compliance, but it’s not clear that this is true in practice. The financial and clinical upside attributed to compliance cannot be definitively determined without direct measurement of both medical and prescription claims information over a long period of time.

Plan Design Considerations

The optimal pharmacy benefit plan design considerations are dependent on the plan sponsor’s goals for member access and cost-share balanced with financial sustainability of the plan. Retail-90 may include restrictions that limit where members can access their benefit (e.g., ability to fill a 90-Day Supply at a specific pharmacy). Retail-90 also may result in higher plan costs through a combination of puts and takes with discounts, decreased rebate yield, and decreased member cost-share. Adjusting the member cost-share within Retail-30 and Retail-90 brands may assist in financially rebalancing the plan and should be considered.

The Bottom Line…

While there are perceived and realized financial and clinical pros and cons to Retail-30 and Retail-90 programs, the data is inconclusive as to which provides the better value from a plan and member perspective. It is recommended that each employer’s pharmacy benefit plan be reviewed against their goals and objectives on a stand-alone basis. Only then can you determine whether Retail-90 or Retail-30 would provide the best value for their specific circumstances.

Download our free Definitive Guide to Optimizing Pharmacy Benefits to learn additional best practices to help your clients manage costs using tailored prescription benefits strategies.