Regulated Markets

Ashley Article

From the Affordable Care Act to Medicaid expansion, and millions of new members becoming eligible for Medicare each year, the face of healthcare is forever changing in the U.S. with broad implications across all regulated markets. These changes present many new challenges for health plans, including:

  • Coping with persistent uncertainty
  • Competing in a world of new benefit and care models
  • Staying compliant with new and changing federal and state regulations

Unprecedented Opportunities

As millions more Americans move to government-regulated coverage, this presents health plans with a tremendous potential for business growth. To attract and retain lives in this environment, you need a proven partner that is highly focused on Medicare, Medicaid and the public exchanges.

We offer unparalleled expertise and experience in supporting regulated markets and continuously make bold investments in areas that matter most. This includes:

  • Investing hundreds of millions of dollars in solutions targeted to regulated markets, including building a deep, focused team of experts dedicated to our clients’ success
  • Proven track record of delivering benefits that are rigorously compliant with all federal and state regulations
  • Specialized service model that provides plans with flexibility and a tailored approach to government programs
  • Innovative solutions to help plans deliver a more tightly managed, cost-effective benefit while improving member health

With more Americans getting their healthcare through Medicare, Medicaid and the exchanges, there’s never been a more critical time for pharmacy benefits. Watch this video to learn how Express Scripts helps health plans win in regulated markets.

 Government Solutions by the Numbers

Constellation Ratings Advisor Overview

Knowing exactly how your Medicare plan is performing across all medical and pharmacy metrics, and which improvements will enhance your future financial returns is critical for your plan's success. Constellation® Ratings Advisor is a simple tool that puts you in the driver's seat in demystifying this increasingly complex challenge.

While the risk adjustment program transfers billions of dollars between health plans participating in the Exchange Marketplace, many plans do not receive full credit for their true patient risk. As a leading indicator of population health, pharmacy claims provide early intelligence to help plans generate more accurate risk scores, maximize risk-adjusted payments and avoid payouts. Express Scripts offers a range of strategies and solutions to optimize your pharmacy benefit, that combine effective patient care solutions with accurate risk intelligence to drive the best possible outcomes. 

Drive Growth With Insights From Our Experts

Looking to gain the edge needed to compete and win in the regulated marketplace? Focus on pharmacy. With pharmacy being the most widely used benefit, having a PBM partner with deep expertise serving Medicare, Medicaid and the growing exchanges market can make a real difference. Our experts have the experience and knowledge to help you win.


Peter WickershamPeter Wickersham Krista WardKrista Ward, MBA
Rebecca RabbittRebecca Rabbitt, PharmD Laura Crawn
Ramesh Jayasuriya Jason Winters
Brittany Neu

Key Insights