2023 Sun Life Stop-Loss high-cost claims and injectable drugs report
For the past eleven years, Sun Life 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 their employees.
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 a deep dive into newborn-related conditions, cardiovascular, orthopedics/musculoskeletal conditions, and more.
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SLDX-1576 SLPC 31610 05/22 (exp. 05/24)
71% 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/Muskoloskeletal
Newborn/ Infant care
Respiratory
Sepsis
Neurological
Gastrointestinal
Urinary/ Renal
Million-dollar claims on a per million covered employees basis rose 15% in the past year and 45% over the past four years.
This year's highest-cost claim was for a member with a primary diagosis of Newborn/Infant Care at $6.5 million in total cost.
2019
2020
2021
2022
109
114
137
158
Top 10 injectable drugs
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
Keytruda
Opdivo
Darzalax Faspro
Tepezza
Soliris
Neulasta
Perjeta
Yervoy
Adcetris
Ocrevus
20% of employers had at least one member with over $1M in claims during the four-year benefit period from 2018 through 2021.
$12.2B total spent on high cost claim conditions in 2019 to 2022 including first dollar stop-loss claim payments and stop-loss 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.
Click here for 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
Leukemia, Lymphoma, Multiple Myeloma
Cardiovascular
Orthopedics/Musculoskeletal
Newborn/Infant Care
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
Leukemia, Lymphoma, Multiple Myeloma
Cardiovascular
Newborn/Infant Care
Orthopedics/Musculoskeletal
$251K–500K
Malignant Neoplasm
Leukemia, Lymphoma, Multiple Myeloma
Newborn/Infant Care
Cardiovascular
Respiratory
Over $500K
Cardiovascular
Leukemia, Lymphoma, Multiple Myeloma
Newborn/Infant Care
Malignant Neoplasm
Neurological
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: $195.3K
Highest cost: $2.38M
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 almost 30% of all stop-loss
reimbursements.
Average cost: $254.7K
Highest cost: $2.11M
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: $89.6K
Highest cost: $2.01K
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: $86.9K
Highest cost: $1.85M
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: $90K
Highest cost: $4.53M
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: $371.8K
Highest cost: $4.93M
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: $130.5K
Highest cost: $4.23M
Medical
64%
Rx
36%
Medical
100%
Medical
68%
Rx
32%
Medical
94%
Rx
6%
Medical
74%
Rx
26%
Medical
82%
Rx
18%
Medical
63%
Rx
37%
Medical
73%
Rx
27%
11 out of the top 20 high-cost injectable drugs are related to the treatment of cancer.
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, 2022.
Top 5 rank from Sun Life book of business data, stop-loss reimbursements from 2019-2022.