Part D Pharmacy Market and Reimbursement Analysis Case Study

Client question

A client needed to understand the pharmacy market and reimbursement landscape for top oncology drugs. The work required both market analysis and reimbursement analysis from Medicare Part D claims, with enough segmentation to distinguish brand versions, generic versions, patient geography, dispensing geography, pharmacy groups, PBMs, and formulations.

Part D market analysis

FastHSR built a market analysis file for the top oncology drugs using Medicare Part D claims from 2018 through the latest available year. For each drug, the analysis split utilization by brand versions versus generic versions, patient county, and pharmacy county.

• Time period: 2018 through the latest available year, summarized by year.
• Segmentation: top oncology drugs, brand/generic status, patient county, and pharmacy county.
• Outputs: number of beneficiaries, expenditures, scripts, and days of supply.
• Total view: overall market totals by drug, version type, geography, and year.

Pharmacy group structure

The pharmacy analysis grouped utilization into chain and affiliate categories so the client could compare specialty, retail, affiliated, and other pharmacy channels.

• Selected pharmacy chain.
• Large chain and affiliates.
• CVS Specialty and affiliates.
• OptumRx and affiliates.
• Walgreens specialty and affiliates, using parent organization information where helpful.
• All other pharmacies.

Part D reimbursement analysis

FastHSR also created a reimbursement analysis for the top oncology drugs. The analysis split each drug by brand versions versus generic versions and, where useful, by formulation such as tablet strength, capsule strength, oral formulation, injectable formulation, or other drug-specific form.

• Time period: 2018 through the latest available year, summarized by year.
• Outputs: reimbursement by drug and reimbursement by unit.
• Drug cuts: brand versions versus generic versions.
• Formulation cuts: strength and formulation where the drug mix required finer segmentation.

Reimbursement metrics

For each drug and cut, FastHSR calculated distributional reimbursement measures rather than relying only on averages. This helped reveal payment variation across claims, PBMs, formulations, and pharmacy channels.

• Average reimbursement by drug.
• Median reimbursement by drug.
• 25th percentile reimbursement by drug.
• 75th percentile reimbursement by drug.
• Average, median, 25th percentile, and 75th percentile reimbursement by unit.
• All metrics split by brand/generic status and, where needed, formulation.

PBM and pharmacy-chain cuts

The reimbursement file included total reimbursement cuts and PBM-specific cuts. PBM groupings included major organizations such as CVS Caremark, Express Scripts, OptumRx, and other PBMs where data supported assignment.

FastHSR also produced the same total and PBM-specific reimbursement cuts for a selected pharmacy chain, allowing the client to compare one chain's reimbursement patterns with the broader market.

Why this required claims-scale pharmacy analytics

Oncology Part D pharmacy analysis requires more than a drug list. FastHSR had to normalize drug names and versions, separate brand and generic claims, identify formulations, assign geography, group pharmacies and affiliates, classify PBM relationships where possible, and calculate utilization and reimbursement measures across many years of Part D claims.

Deliverables

• Annual Part D oncology market file from 2018 through the latest available year.
• Number of beneficiaries, expenditures, scripts, and days of supply by drug, brand/generic status, patient county, pharmacy county, and pharmacy group.
• Reimbursement by drug and reimbursement by unit.
• Average, median, 25th percentile, and 75th percentile reimbursement benchmarks.
• Total, PBM-specific, and selected pharmacy-chain reimbursement cuts.
• Brand/generic and formulation-level outputs for top oncology drugs.

Use cases

• Oncology pharmacy market sizing and share analysis.
• Specialty pharmacy channel strategy.
• PBM reimbursement benchmarking.
• Brand-to-generic transition monitoring.
• County-level patient and pharmacy geography analysis.
• Pharmacy-chain and affiliate performance evaluation.

Frequently asked questions

How can Part D claims support pharmacy market analysis?

Part D claims can measure scripts, days of supply, expenditures, drug mix, pharmacy location, patient geography, brand and generic versions, and pharmacy-chain groupings over time.

How can Part D claims support reimbursement analysis?

Part D claims can be used to estimate reimbursement by drug and reimbursement by unit, including average, median, 25th percentile, and 75th percentile values by drug, brand/generic status, formulation, PBM, and pharmacy group.

Why split oncology drugs by brand and generic versions?

Brand and generic versions can have different utilization patterns, pharmacy channels, reimbursement levels, formulation mix, and competitive dynamics, so separating them improves market and reimbursement interpretation.

Which pharmacy and PBM groupings can be analyzed?

Analyses can group claims by specialty and retail pharmacy chains, chain affiliates, other pharmacies, and PBMs such as CVS Caremark, Express Scripts, OptumRx, and similar organizations where data support assignment.

For Part D pharmacy market analysis, oncology drug reimbursement analytics, PBM benchmarking, or specialty pharmacy strategy, please email us.

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