Enlyte released its 2026 In-Network and Out-of-Network Drug Trends report on July 31, covering 2025 calendar-year pharmacy claims across workers’ compensation and auto casualty. The headline number: prescriptions filled outside a managed pharmacy network cost an average of 67% more than the same therapeutic category filled in-network.
That gap is not an actuarial abstraction. For a self-insured employer setting case reserves on open workers’ compensation (WC) medical claims, every out-of-network (OON) prescription that processes against a reserve calibrated to in-network benchmarks creates an understatement. The shortfall compounds across open files and does not surface in development factors until paid claims catch up to the true liability.
Who It Affects
Self-insured employers and group pools with significant WC exposure in physician-dispensing states carry the highest concentration of this risk. Florida accounts for 59% of total WC pharmacy spend filling outside the network in Enlyte’s dataset, a direct consequence of state rules allowing physicians to dispense branded topicals and specialty formulations at the point of care. New York sits at the opposite end: 88% of WC pharmacy spend flows in-network there, the result of a state formulary that constrains physician dispensing.
Programs with Florida exposure are operating under a materially different OON intensity than national averages suggest. Captive managers and stop-loss underwriters reviewing WC medical triangles from physician-dispensing states should treat OON share as a program-specific severity variable, not a plan-design nuance.
Reserve Mechanism
The mechanism is case adequacy. When an actuary sets the expected medical cost per open WC claim, the benchmark typically reflects managed-care program experience with integrated formulary controls. Enlyte’s data show that programs without clinical controls pay 41% more per claim in total pharmacy cost than those with integrated management; 58% of that differential comes specifically from OON migration.
The cost gap by therapeutic class:
- Muscle relaxants: 69% more OON than in-network
- Topical medications: 62% more OON; topicals represent 41% of all OON WC pharmacy spend, concentrated in states where physician dispensing rules allow high-dollar specialty formulations to move at point-of-care
- NSAIDs and opioids: 35-38% more OON, affecting routine prescription volume across any open claim file
CGRP inhibitors (a newer class of migraine-prevention drugs) represent the emerging tail risk. Per Enlyte, CGRP scripts now run $970 to $2,000 each and grew nearly 10% in both cost and utilization in 2025. An open claim with migraine as a comorbidity and no clinical controls on specialty prescribing carries a pharmacy tail that standard benchmarks do not capture.
The Florida court ruling that blocked physician drug dispensing in WC claims removed one layer of this risk for some Florida programs, but Enlyte’s 2025 data confirm that OON pharmacy spend remains concentrated in that state. For the broader cost evidence on network routing, WCRI’s 34-state analysis found that in-network claims cost $11,820 less at three years, with medical savings the primary driver.
What This Means for Your Next Review
At your next reserve study or interim monitoring meeting, confirm what benchmark your actuary is using for the medical cost component of open WC case reserves. If it reflects managed-care program experience and your program operates in physician-dispensing states, ask for a state-level breakdown of OON pharmacy share by open claim. The 67% cost premium applies to the pharmacy component of every case reserve where prescriptions are currently processing outside the network; the aggregate reserve load is quantifiable once OON share is known.
Open claims with CGRP inhibitors appearing in the file warrant individual reserve review. At $970 to $2,000 per script, a single comorbid migraine claim can materially exceed a case reserve set on average pharmacy benchmarks.
The broader question for your IBNR analysis is whether pharmacy development on recent accident years is consistent with prior accident years, or whether OON migration is accelerating. If your managed pharmacy network participation has declined over the past two to three years, development factors derived from older accident years may no longer reflect current cost emergence. WC IBNR fundamentals for self-insured employers covers where pharmacy cost shifts appear in the development triangle and how to adjust for program changes mid-triangle.
Sources
- Enlyte 2026 In-Network and Out-of-Network Drug Trends Report (July 31, 2026)
- WorkCompWire: Enlyte Releases In-Network and Out-of-Network Drug Trends Report
- Business Insurance: Out-of-network drug costs 67% higher in workers comp
- Enlyte Drug Trends Data Portal
- WCRI: Workers’ Compensation Prescription Drug Regulations, A National Inventory, 2026