2022 Sun Life Stop-Loss High-Cost Claims and Injectable Drugs Report
Every year, Sun Life shares latest insights from our claims experience to help self-funded employers prepare for potential high-cost claims. Our robust data set allows us to report on persistent themes, as well as emerging trends.
For this year’s report, our high-cost claims and injectable drug trends analysis provides insights on top claim conditions, million-dollar claims, injectable drugs, and trends we are seeing since the COVID-19 pandemic began.
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Sun Life Stop-Loss Highlights
2,800+ policyholders
$5.0B total claim reimbursements
$2.4B in premium (year end 2021)
5.3M covered lives
10 years of research and counting!
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GSLCR-10409 SLPC 31610 05/22 (exp. 05/24)
75% of all reimbursed stop-loss claims are from the top 10 conditions
Top 10 Conditions
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
Malignant Neoplasm
Leukemia, Lymphoma, Multiple Myeloma
Cardiovascular
Orthopedics/Musculoskeletal
Newborn/Infant Care
Respiratory
Urinary/Renal
Neurological
Gastrointestinal/Abdominal
Sepsis
Million-dollar+ claims are up 21% in 2021 and up 37% since 2018
The highest-cost claim in 2021 was for Hemophilia/Bleeding Disorder at $6.23M
2018
2019
2020
2021
203
235
255
303
Top 10 Injectable Drugs
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
Keytruda
Opdivo
Neulasta
Soliris
Perjeta
Tepezza
Herceptin
Ocrevus
Zolgensma
Avastin
COVID-19 was ranked #19 this year with only two years of claims in comparison to other conditions having four years of claims.
$11.1B total spent on high cost claim conditions: first-dollar stop-loss claim payments and stop-loss claim reimbursements
Ten years ago, we produced our high-cost claims and injectable drug trends report (originally called the Catastrophic Claims Report) for the first time. Since then, we’ve made a commitment to sharing our most actionable and informative insights to help employers make the best decisions around your self-funded benefits.
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Top five high cost conditions by deductible level
All Deductible Levels
$0–$50,000
$51,000–$100,000
$101,000–$250,000
$251,000–$500,000
OVER $500,000
Click on each condition to learn more
Condition
1.
2.
3.
4.
5.
ALL DEDUCtiBLE LEVELS
Malignant neoplasm
Leukemia, lymphoma, and/or multiple myeloma
Cardiovascular disease/disorder
Orthopedics/Musculoskeletal disease/disorder
Newborn/Infant care disease/disorder
$0–$50,000
Malignant neoplasm
Orthopedic/ Musculoskeletal disease/disorder
Cardiovascular disease/disorder
Gastrointestinal/ abdominal disease/disorder
Sepsis
$51,000–$100,000
Malignant neoplasm
Cardiovascular disease/disorder
Leukemia, lymphoma, and/or multiple myeloma
Orthopedic/ Musculoskeletal disease/disorder
Newborn/infant care disease/disorder
$101,000–$250,000
Malignant neoplasm
Leukemia, lymphoma, and/or multiple myeloma
Cardiovascular disease/disorder
Newborn/infant care disease/disorder
Orthopedic/ Musculoskeletal disease/disorder
$251,000–$500,000
Malignant neoplasm
Leukemia, lymphoma, and/or multiple myeloma
Newborn/infant care disease/disorder
Cardiovascular disease/disorder
Respiratory disease/disorder
Over $500,000
Newborn/infant care disease/disorder
Cardiovascular disease/disorder
Transplant
Leukemia, lymphoma, and/or multiple myeloma
Neurological disease/disorder
Malignant neoplasm
This category contains diagnoses of what are commonly thought of as solid tumors, including treatment for the tumor, secondary conditions directly related to the tumor, and/or its treatment. Malignant neoplasm claims are over double the spend of the second most expensive condition: Leukemia, lymphoma, and/or multiple myeloma (blood cancers)
Average cost: $170.4K
Highest cost: $2.09M
Leukemia, lymphoma and/or multiple myeloma
This category contains acute and chronic diagnoses of what are commonly thought of as cancers of the blood, secondary conditions directly related to leukemia, and/or its treatment. Cancer continues to hold the top #1 and #2 spot, with total stop-loss reimbursement of $1.5B over the past four years. This makes up 30% of all stop-loss
reimbursements.
Average cost: $258K
Highest cost: $4.83M
Neurological
This category contains acute and chronic disease and injury related to the neurological system, including traumatic injury, primary and acquired disease, infectious disease, secondary conditions directly related to neurological compromise, and complications of treatment. This category combines what was previously five separate categories.
Average cost: $185K
Highest cost: $4.6M
Sepsis
This category contains disease and injury related to septicemia and septic shock, including infectious agents (excluding COVID-19). Only Sepsis is included within this category, making it a clear comparison to Septicemia in our prior reports.
Average cost: $179.6K
Highest cost: $2.21M
This category contains disease and injury related to the gastrointestinal system (mouth to anus), including traumatic injury, infectious disease, thoracic organ disease, dental conditions covered under medical plan, oral and pharyngeal-esophageal disease, secondary conditions directly related to GI system compromise, and complications of treatment.
Average cost: $70K
Highest cost: $934K
Gastrointestinal/Abdominal
Respiratory
This category contains acute and chronic disease and injury related to the respiratory system, including primary and acquired disease, infectious disease, pulmonary heart disease, secondary conditions directly related to respiratory dysfunction, and complications of treatment. This category includes five conditions from our prior claims mapping.
Average cost: $80K
Highest cost: $4.04M
Transplant
Transplants by ICD-10 code include the transplantation of solid organs as well as blood and stem cells. In 2019 alone, there were nearly 40,000 solid organ transplants performed in the U.S. with most recipients being between the ages of 50-64.*
Average cost: $184K
Highest cost: $2.53M
*United Network for Organ Sharing, 2020.
Hemophilia/Bleeding disorder
Rare genetic disorders where blood does not clot as it normally should. These can result in extensive internal and external bleeding. Hemophilia affects approximately 1 in every 5,000 men (currently about 20,000 in the U.S), with about half being the more severe form.*
*Center for Disease Control and Prevention, June 3rd, 2019. What is Hemophilia?
Average cost: $450K
Highest cost: $4.9M
Orthopedics/ Musculoskeletal
This category contains acute and chronic disease and injury of bone and soft tissue, including traumatic injury, primary and acquired disease and deformity, secondary conditions directly related to orthopedic dysfunction, and complications of
treatment. The #4 ranking is due heavily to eight of our previous categories being included in this body system grouping.
Average cost: $75.8K
Highest cost: $1.97M
Newborn
This category contains disease
and injury related to newborn infants, including disease and complications of prematurity and/or low birthweight, complications related to maternal conditions, complications and birth trauma related to labor/delivery, dysfunction related to immaturity of body systems, and complications of treatment. Four categories from our prior grouping system are now included in this condition.
*Center for Disease Control and Prevention, June 3rd, 2019. What is Hemophilia?
Average cost: $318.0K
Highest cost: $3.51M
Choose a deductible level:
Cardiovascular
This category contains acute and chronic disease and injury related to the heart and blood vessels, including primary and acquired disease, traumatic injury, secondary conditions directly related to cardiovascular dysfunction, and
complications of treatment.
Average cost: $102K
Highest cost: $2.45M
Medical
68%
Rx
32%
Medical
99%
Rx
1%
Medical
69%
Rx
31%
Medical
93%
Rx
7%
Medical
95%
Rx
5%
Medical
81%
Rx
19%
Medical
83%
Rx
17%
Medical
72%
Rx
28%
Medical
74%
Rx
26%
Medical
96%
Rx
4%
