New Analysis: Health Exchange Medication Trends

Oct 7, 2014
The second Express Scripts Exchange Pulse Report reveals nearly half of Americans enrolled in a Public Health Insurance Exchange plan have already used their pharmacy benefit.
  • Public Exchanges
  • Depression
  • Contraceptives
  • Pain
  • Hepatitis C
  • HIV
  • High Blood Pressure/Heart Disease


Download the second Exchange Pulse Report with updated data on both public exchange and off-exchange members.

At Express Scripts, we’re uniquely positioned to leverage our actionable data and provide comprehensive insights about how patients enrolled in the Public Health Exchanges are using their benefit. In April, we provided the nation’s first look at early medication utilization trends in the Exchanges, which showed the earliest enrollees in those plans were using more specialty medications than traditionally insured Americans.

Today we released our second Exchange Pulse ReportTM, showing that Americans enrolled in the Exchanges are:

  • Using their pharmacy benefit
  • More likely to use generic medications
  • Filling more prescriptions for specialty medications

Nearly 50% of Patients in a Health Exchange Plan Used Their Benefits

Exchange enrollees, including those who enrolled after March 1, are using their pharmacy benefit in a manner consistent with traditionally insured Americans (55%), who are more likely to have been insured since January and be more familiar with health insurance. Exchange enrollees are paying premiums, seeing their physicians and filling prescriptions, which is good news for both patients and health plans that participate in the Exchange.

Exchange Members Use More Generics

Exchange plans have an 87% generic fill rate, which is 6% higher than the traditionally insured population.

Generic Fill Rate

Exchange plans with lower premiums but higher out-of-pockets costs for brand-name medications (Silver Plans) have been the most popular among consumers on the Exchanges, particularly among those eligible for subsidies. By preferring generic medications over more expensive brand-name alternatives, these members are using their plans in the way they were designed.

Later Enrollees Are Younger, Use Fewer Medications

The analysis also examined prescription use for later enrollees – those who signed up on or after March 1 – and found that they are younger by an average of four years, use fewer medications and have lower incomes than the earlier enrollees in these plans.

Prevalence of Top Conditions Among Early and Later Enrollees

Health Exchange Members Income Early and Later Enrollees

Higher Utilization of Specialty Medications Within the Exchanges

Exchange enrollees fill 59% more prescriptions for specialty medications than other insured individuals. This disparity is especially pronounced in Exchange enrollees ages 18 to 34, who fill twice as many specialty medications as similarly aged individuals in traditional health plans.

Nearly 3 out of 5 specialty prescriptions filled by Exchange members are for HIV medication.

Top Ten Drug Classes by Specialty Claims Volume 

Despite accounting for only 1.3% of total pharmacy claims, specialty medications consume 38% of the total pharmacy spend for the Exchange plans. By comparison, only 28% of the total pharmacy spend for traditional health plans is attributed to specialty drugs.

Need for Clinical Specialization

Given the increased prevalence of specialty conditions, it’s vitally important for these Exchange plans to provide patients with clinical programs that ensure appropriate management of complex, high-cost medications.

Enrollees in an Exchange plan with a pharmacy benefit administered by Express Scripts have access to specialist pharmacists who can help these patients optimize their prescription therapy and get the most from their benefit, leading to better health outcomes and reduced costs.

For example, HIV specialist pharmacists have the in-depth clinical training and experience necessary to identify causes that may lead to therapy failure and resistance. They will interact with the patient and the patient’s healthcare team to address such things as drug interactions, side effects, abnormal doses and therapy omissions.

About the Analysis

The Express Scripts Exchange Pulse Report compared prescription drug utilization within the Exchange plans to trends in the traditionally insured population.

Author Bio

Julie Huppert
comments powered by Disqus