Exchange Pulse Report, October 2014

Oct 13, 2014
Providing the nation's foremost look at the health and prescription drug use of both public health exchange and off-exchange members.

October Hix

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Exchange Pulse™ Report Summary

The Affordable Care Act (ACA) individual mandate requires Americans to obtain health insurance that meets certain minimum requirements or pay a tax penalty. As a result, millions of individuals are purchasing health coverage directly from health plan providers, either through the public health exchanges (on-exchange) or on their own (off-exchange).

This latest Exchange Pulse™ report, the second in our series, is the nation’s foremost look at the health and prescription drug use of both public health exchange and off-exchange members.

Pharmacy is the health benefit used more often by members. Unlike medical claims, pharmacy claims adjudicate in real time, providing the industry’s earliest indication of member health and medication usage and costs. With access to more than 1 billion pharmacy claims annually, coupled with clinical expert analysis, Express Scripts is uniquely positioned to share actionable insights and emerging trends. Through our series of Exchange Pulse reports, Express Scripts helps insurers better understand their health plan populations and successfully compete in the regulated healthcare market.

Key Findings

  • Health exchange members are using their pharmacy benefit
  • Later enrollees are younger and have fewer health conditions
  • Specialty medication use and spending is higher, especially for HIV
  • Plan design is driving generic drug use and member cost-share
  • Off-exchange drug costs are significantly higher

About the Analysis

This report analyzes trends in prescription medication use for individuals enrolled in public health exchange and off-exchange plans and compares these trends to those of commercial health plan members. This comprehensive analysis is based on 80 million de-identified pharmacy claims data for members who had pharmacy benefit coverage administered by Express Scripts and who filed pharmacy claims between January 1, 2014, and July 31, 2014.