For additional assistance on 

benefits, contact one of our 

information offices:

NATIONAL: WASHINGTON, DC

(202) 691-6199 TDD: (800) 877-8339

NCSinfo@bls.gov www.bls.gov/ebs

REGIONAL:

ATLANTA

(404) 893-4222

BOSTON

(617) 565-2327

CHICAGO

(312) 353-1880

DALLAS

(972) 850-4800

KANSAS CITY

(816) 285-7000

NEW YORK

(646) 264-3600

PHILADELPHIA

(215) 597-3282

SAN FRANCISCO

(415) 625-2270

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

www.bls.gov/ebs 

GLOSSARY

The next Program Perspectives will feature 

Health Benefit Costs by Wage Category

Access to a plan. Employees are considered 

to have access to a benefit plan if it is available for their use. For example, if an employee is permitted to participate in a health 

plan offered by the employer, he or she is 

placed in a category with those having access to a health plan, regardless of whether 

the employee chooses to participate.

Participation. Participation is the percentage of employees who actually enroll in a 

benefit plan. A plan may be a contributory 

plan, which requires an employee to contribute to the plan’s cost in order to participate, or it may be a noncontributory plan, in 

which the employer pays 100 percent of the 

cost of the benefit. 

Takeup rate of a benefit plan. The takeup 

rate is the percentage of workers with access to a plan who participate in the plan. 

Takeup rates are computed by dividing the 

number of workers participating in a plan 

by the number of workers with access to 

the plan, multiplying by 100, and rounding 

to the nearest percent. 

Brand-name drugs. These are drugs that 

once were, or still are, under patents.

Generic drugs. These are drugs that are not 

under any patent. Once a drug’s patent has 

expired, some plans provide more generous 

coverage for same-formula generic drugs 

than for name-brand drugs; the practice is 

adopted as a cost containment measure.

Mail-order drugs. These are drugs that 

can be ordered through the mail. As a cost 

containment measure, some plans use mailorder pharmacies that typically provide several month’s worth of maintenance drugs.

Formulary drugs. These are drugs that are 

approved by the health care provider. Drugs 

that are not approved by the health care 

provider are nonformulary drugs, for which 

enrollees receive less generous benefits, such 

as a higher copayment per prescription. 

Coinsurance. This form of medical cost 

sharing requires an insured person to pay a 

stated percentage of medical expenses after 

the deductible amount, if any, is paid. After 

any deductible amount and coinsurance are 

paid, the insurer is responsible for the rest 

of the reimbursement for covered benefits, 

up to the maximum allowed charges. The 

individual is responsible for any charges in 

excess of what the insurer determines to be 

“usual, customary, and reasonable.” Coinsurance rates may differ between services 

received from an approved provider and 

those received from providers that are not 

on the approved list. 

for higher reimbursed formulary 

drugs increased from 44 percent in 

2005 to 74 percent in 2009. (See 

table 2.)

Copayments

Although workers have outpatient prescription coverage, copayment exists as an additional cost 

for many. A copayment is a payment made by an individual who 

has health insurance, to offset 

some of the cost of care. Usually, 

the copayment is made at the time 

a service is received. Most workers 

are in plans that require a copayment for each prescription—a set 

amount, rather than a proportion 

of the prescription’s price. For example, under this type of plan, the 

enrollee would pay $10 for each 

prescription filled, regardless of 

whether the retail cost of the same 

purchase would be $10 or $100. 

Eighty-two percent of all workers 

had copayment restrictions for 

generic drugs, the median copayment of which was $10 per 

prescription. Seventy-nine percent of workers had copayment 

restrictions for brand-name drugs, 

the median copayment of which 

was $25 per prescription. Median 

copayments for generic drugs and 

for brand-name drugs were similar 

at $10 and $25, respectively, for 

full- and part-time workers, for 

union and nonunion members, 

by industry, and by establishment 

size. Those plan participants who 

are not subject to a copayment 

may have other limits imposed, 

such as paying a proportion of the 

cost of the drug. ●
U.S. BUREAU OF LABOR STATISTICS 

(ability to receive benefits) to outpatient prescription drug coverage and 

50 percent actually received outpatient prescription drug benefits. The 

takeup rate, which is the percentage 

of workers with access to outpatient 

prescription drug coverage who 

actually participated in this benefit, 

was 73 percent. (See table 1.)

Outpatient prescription drug coverage varied widely by worker char

2 PROGRAM PERSPECTIVES • AUGUST 2011 

acteristics. Private industry workers in management, professional, 

and related occupations had nearly 

double the access rate of service 

workers for outpatient prescription 

drug coverage, and participation was 

65 percent and 27 percent, respectively. Full-time worker particpation (62 percent) was significantly 

higher than part-time participation 

(13 percent). Union workers also had 

greater access and participation rates 

compared with nonunion workers. 

Higher wage workers (the highest 25 percent of wage earners) had 

greater access and participation in 

outpatient prescription drug coverage than lower wage workers (the 

lowest 25 percent). Participation for 

the lowest 25 percent of wage earners was just 21 percent, compared 

with 70 percent for the highest 25 

percent of wage earners. The take

from cover page►

Outpatient prescription drug coverage: access, participation, and takeup rates,

private industry workers, National Compensation Survey, March 2010

All workers = 100 percent

TABLE 1

Characteristics Access Participation Takeup rate

Worker characteristic 69 50 73

All workers

Management, professional, and related 85 65 76

Service 44 27 61

Sales and office 70 49 69

Natural resources, construction, and maintenance 74 58 78

Production, transportation, and material moving 74 57 77

Full time 84 62 74

Part time 23 13 57

Union 89 75 84

Nonunion 67 47 71

Wage percentiles

 Lowest 25 percent 37 21 57

 Second 25 percent 74 51 69

 Third 25 percent 84 65 77

 Highest 25 percent 89 70 79

Establishment characteristics

1 to 49 workers 54 38 70

50 to 99 workers 68 49 72

100 to 499 workers 80 57 71

500 or more workers 86 67 78
U.S. BUREAU OF LABOR STATISTICS 

(ability to receive benefits) to outpatient prescription drug coverage and 

50 percent actually received outpatient prescription drug benefits. The 

takeup rate, which is the percentage 

of workers with access to outpatient 

prescription drug coverage who 

actually participated in this benefit, 

was 73 percent. (See table 1.)

Outpatient prescription drug coverage varied widely by worker char

2 PROGRAM PERSPECTIVES • AUGUST 2011 

acteristics. Private industry workers in management, professional, 

and related occupations had nearly 

double the access rate of service 

workers for outpatient prescription 

drug coverage, and participation was 

65 percent and 27 percent, respectively. Full-time worker particpation (62 percent) was significantly 

higher than part-time participation 

(13 percent). Union workers also had 

greater access and participation rates 

compared with nonunion workers. 

Higher wage workers (the highest 25 percent of wage earners) had 

greater access and participation in 

outpatient prescription drug coverage than lower wage workers (the 

lowest 25 percent). Participation for 

the lowest 25 percent of wage earners was just 21 percent, compared 

with 70 percent for the highest 25 

percent of wage earners. The take

from cover page►

Outpatient prescription drug coverage: access, participation, and takeup rates,

private industry workers, National Compensation Survey, March 2010

All workers = 100 percent

TABLE 1

Characteristics Access Participation Takeup rate

Worker characteristic 69 50 73

All workers

Management, professional, and related 85 65 76

Service 44 27 61

Sales and office 70 49 69

Natural resources, construction, and maintenance 74 58 78

Production, transportation, and material moving 74 57 77

Full time 84 62 74

Part time 23 13 57

Union 89 75 84

Nonunion 67 47 71

Wage percentiles

 Lowest 25 percent 37 21 57

 Second 25 percent 74 51 69

 Third 25 percent 84 65 77

 Highest 25 percent 89 70 79

Establishment characteristics

1 to 49 workers 54 38 70

50 to 99 workers 68 49 72

100 to 499 workers 80 57 71

500 or more workers 86 67 78
For additional assistance on 

benefits, contact one of our 

information offices:

NATIONAL: WASHINGTON, DC

(202) 691-6199 TDD: (800) 877-8339

NCSinfo@bls.gov www.bls.gov/ebs

REGIONAL:

ATLANTA

(404) 893-4222

BOSTON

(617) 565-2327

CHICAGO

(312) 353-1880

DALLAS

(972) 850-4800

KANSAS CITY

(816) 285-7000

NEW YORK

(646) 264-3600

PHILADELPHIA

(215) 597-3282

SAN FRANCISCO

(415) 625-2270

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

www.bls.gov/ebs 

GLOSSARY

The next Program Perspectives will feature 

Health Benefit Costs by Wage Category

Access to a plan. Employees are considered 

to have access to a benefit plan if it is available for their use. For example, if an employee is permitted to participate in a health 

plan offered by the employer, he or she is 

placed in a category with those having access to a health plan, regardless of whether 

the employee chooses to participate.

Participation. Participation is the percentage of employees who actually enroll in a 

benefit plan. A plan may be a contributory 

plan, which requires an employee to contribute to the plan’s cost in order to participate, or it may be a noncontributory plan, in 

which the employer pays 100 percent of the 

cost of the benefit. 

Takeup rate of a benefit plan. The takeup 

rate is the percentage of workers with access to a plan who participate in the plan. 

Takeup rates are computed by dividing the 

number of workers participating in a plan 

by the number of workers with access to 

the plan, multiplying by 100, and rounding 

to the nearest percent. 

Brand-name drugs. These are drugs that 

once were, or still are, under patents.

Generic drugs. These are drugs that are not 

under any patent. Once a drug’s patent has 

expired, some plans provide more generous 

coverage for same-formula generic drugs 

than for name-brand drugs; the practice is 

adopted as a cost containment measure.

Mail-order drugs. These are drugs that 

can be ordered through the mail. As a cost 

containment measure, some plans use mailorder pharmacies that typically provide several month’s worth of maintenance drugs.

Formulary drugs. These are drugs that are 

approved by the health care provider. Drugs 

that are not approved by the health care 

provider are nonformulary drugs, for which 

enrollees receive less generous benefits, such 

as a higher copayment per prescription. 

Coinsurance. This form of medical cost 

sharing requires an insured person to pay a 

stated percentage of medical expenses after 

the deductible amount, if any, is paid. After 

any deductible amount and coinsurance are 

paid, the insurer is responsible for the rest 

of the reimbursement for covered benefits, 

up to the maximum allowed charges. The 

individual is responsible for any charges in 

excess of what the insurer determines to be 

“usual, customary, and reasonable.” Coinsurance rates may differ between services 

received from an approved provider and 

those received from providers that are not 

on the approved list. 

for higher reimbursed formulary 

drugs increased from 44 percent in 

2005 to 74 percent in 2009. (See 

table 2.)

Copayments

Although workers have outpatient prescription coverage, copayment exists as an additional cost 

for many. A copayment is a payment made by an individual who 

has health insurance, to offset 

some of the cost of care. Usually, 

the copayment is made at the time 

a service is received. Most workers 

are in plans that require a copayment for each prescription—a set 

amount, rather than a proportion 

of the prescription’s price. For example, under this type of plan, the 

enrollee would pay $10 for each 

prescription filled, regardless of 

whether the retail cost of the same 

purchase would be $10 or $100. 

Eighty-two percent of all workers 

had copayment restrictions for 

generic drugs, the median copayment of which was $10 per 

prescription. Seventy-nine percent of workers had copayment 

restrictions for brand-name drugs, 

the median copayment of which 

was $25 per prescription. Median 

copayments for generic drugs and 

for brand-name drugs were similar 

at $10 and $25, respectively, for 

full- and part-time workers, for 

union and nonunion members, 

by industry, and by establishment 

size. Those plan participants who 

are not subject to a copayment 

may have other limits imposed, 

such as paying a proportion of the 

cost of the drug. ●