High-cost claims and injectable drugs analysis
For the past twelve years, Sun Life has analyzed our claims data to help self-funded employers understand trends and potential impacts of the highest-cost medical and injectable drug claims. We share this analysis annually to help employers make benefit and risk management decisions that are right for their business and employees.
This year's high-cost claims and injectable drug trends analysis provides insights on top claim conditions, million-dollar+ claims, injectable drugs, and a deep dive into newborn-related conditions, cardiovascular, cancer, and more.
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72% 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
Cardiovascular
Leukemia, Lymphoma, Multiple Myeloma
Newborn/Infant care
Orthopedics/Musculoskeletal
Respiratory
Sepsis
Neurological
Gastrointestinal
Urinary/Renal
Million-dollar claims on a per million covered employees basis rose 8% in the past year and 50% over the past four years.
This year's highest-cost claim was for a member with a primary diagosis of Newborn/Infant Care at $11.5 million in total cost.
2020
2021
2022
2023
114
137
158
171
Top 10 injectable drugs
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
Keytruda
Opdivo
Darzalax Faspro
Tepezza
Ultomiris
Perjeta
Adcetris
Neulasta
Ocrevus
Yervoy
Click here to watch the webinar recording!
Top five high cost conditions by deductible level
All Deductible Levels
Up to $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
Cardiovascular
Leukemia, Lymphoma, Multiple Myeloma
Newborn/Infant Care
Orthopedics/Musculoskeletal
Up to $50K
Malignant Neoplasm
Orthopedics/Musculoskeletal
Cardiovascular
Leukemia, Lymphoma, Multiple Myeloma
Gastrointestinal/Abdominal
$51K–100K
Malignant Neoplasm
Cardiovascular
Leukemia, Lymphoma, Multiple Myeloma
Orthopedics/Musculoskeletal
Newborn/Infant Care
$101K–250K
Malignant Neoplasm
Cardiovascular
Leukemia, Lymphoma, Multiple Myeloma
Newborn/Infant Care
Orthopedics/Musculoskeletal
$251K–500K
Malignant Neoplasm
Leukemia, Lymphoma, Multiple Myeloma
Cardiovascular
Newborn/Infant Care
Respiratory
Over $500K
Newborn/Infant Care
Cardiovascular
Malignant Neoplasm
Leukemia, Lymphoma, Multiple Myeloma
Respiratory
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: $213.3K
Highest cost: $2.7M
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.
Average cost: $222.2K
Highest cost: $2.1M
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: $97.5K
Highest cost: $2.86M
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: $96.5K
Highest cost: $2.4M
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: $99.5K
Highest cost: $5.5M
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.
Average cost: $102.5K
Highest cost: $3.3M
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.
Average cost: $470.8K
Highest cost: $11.5M
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: $144.2K
Highest cost: $5.3M
Medical
61%
Rx
39%
Medical
100%
Medical
66%
Rx
34%
Medical
94%
Rx
6%
Medical
71%
Rx
29%
Medical
82%
Rx
18%
Medical
65%
Rx
35%
Medical
73%
Rx
27%
Source: average cost, highest cost, and % medical and rx spend from Sun Life book of business data including first-dollar claims and stop-loss reimbursements, 2023.
Top 5 rank from Sun Life book of business data, stop-loss reimbursements from 2020-2023.
Group stop-loss insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 07-SL REV 7-12 and 22-SL. In New York, Group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12 and 22-NYSL. Policy offerings may not be available in all states and may vary due to state laws and regulations. Not approved for use in New Mexico.
© 2024 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us.
SLDX-1573-2-a #1362359261 05/24 (exp. 05/26)
Click here to view some recently asked questions about the 2023 High Cost Claims and Injectable drugs report.
Recently asked questions
What period of time covers average cost?
Average costs are determined by the total claimant cost for the 2022 paid year.
What kinds of claims are under "malnutrition"?
Metabolic Disorders that lead to malnutrition are one of the main stop-loss claims within the category. Metabolic disorders require medications that are used throughout the day to support better absorption of nutrients.
What category includes Multiple Schlerosis?
Multiple Sclerosis is under the Immune System disorders and makes up about 43.9% of the claims we see in that category.
Does the dollar amount for injectable drugs include the full cost or only the amount above the ISL?
The dollar amount represents the full cost of each injectable drug?
Is case management available from Sun Life for moving treatment to a lower cost location?
Sun Life’s Clinical 360 program uses claims data to identify cost savings and care optimization opportunities for our members. Our Sun Life clinical experts and claims team work as a second set of eyes to optimize care and costs, and the program is available to all Sun Life Stop-Loss clients at no additional charge.
7 of the top 10 injectable drugs are used to treat cancer.
Key Insights
Over the 2019-2022 benefit years, 87% of employers were likely to experience a stop-loss claim in any given year.
COVID has fallen to #29 on our list in 2023, compared to #11 in the single year for 2022.
The primary driver of cost for 50% of members with a the $3M+ claim was congenital anomalies.
The top 10 injectable drugs all had over $10M in total spend. Keytruda at #1 had $69.7M in spend.
Over 50% (11 injectable drugs) of the top 20 are used to treat cancer.
2024 Sun Life Stop-Loss