San Diego, CA – Enlyte recently released its 2026 In-Network vs. Out-of-Network Drug Trends analysis, drawn from 2025 calendar-year pharmacy claims across workers’ comp and auto casualty lines.
The Drug Trends report provides a comprehensive examination of prescription utilization across both in-network and out-of-network (OON) channels, including retail pharmacies, mail-order services, and paper-based medical bill submissions. This dual-lens approach captures the full prescription landscape that extends beyond traditional pharmacy benefit management reporting, revealing critical cost and utilization patterns across all jurisdictions.
While in-network channels demonstrate the real-time effectiveness of integrated clinical controls and cost management strategies, out-of-network data, often representing acute treatment episodes captured through medical bill review, exposes significant cost management opportunities and pricing anomalies. Together, these perspectives illuminate where pharmacy dollars are spent, how prescriptions are managed, and where targeted interventions can drive the greatest impact on both clinical outcomes and costs.
Key findings included:
- Scripts in the same drug category cost 67% more on average when filled out-of-network vs. in-network, rising to 69% for muscle relaxants and 62% for topicals.
- In New York state, in-network prescriptions there actually cost MORE per script than out-of-network fills, driven by prescribers selecting high-cost versions of formulary-listed drugs that bypass prior authorization.
- Clients using integrated clinical decision support cut total pharmacy spend by 18.4%, with the out-of-network channel — a smaller slice of total volume — driving 58% of those savings.
- “Opportunistic” product interventions (targeting inflated or unnecessary dispensing) delivered $915 in average savings per script, nearly 4x the impact of standard interventions.
- Florida, New York, Pennsylvania, Tennessee, and Illinois topped the list for total drug spend, largely shaped by state rules on physician dispensing and pharmacy direction of care.
Read the free report: Enlyte: In-Network and Out-of-Network Drug Trends
Source: Enlyte
Disclosure:
Enlyte has advertised with WorkCompWire.
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