First Look: Health Exchange Medication Utilization

Apr 9, 2014

Express Scripts analysis reveals first look at medication utilization trends among Public Health Insurance Exchange enrollees.

  • Contraceptives
  • Depression
  • Hepatitis C
  • HIV
  • Pain
  • Seizures
  • Adults


April 2014 Update: View an updated version of the Exchange Pulse™ report with an extra month (March) of data and analysis.

Unlike medical claims that can take several months to process, pharmacy claims adjudicate in real time. And as the country’s largest provider of pharmacy benefits – the health benefit most often used among consumers – Express Scripts is uniquely positioned to leverage our actionable data and provide early insights regarding how patients enrolled in the Public Health Exchanges are using this new benefit.

Today, we released the country’s first look at medication utilization in the early stages of the Exchanges, highlighting emerging trends that can help the healthcare system ensure that these patients – who in some cases are new to therapy or even new to having insurance – receive the right level of clinical support so they can achieve overall healthier outcomes.

Specialty Use Greater Among Exchange Plan Enrollees

Our early analysis reveals that, in January and February, use of specialty medications was greater among Exchange enrollees versus patients enrolled in a commercial health plan. Approximately 1.1% of total prescriptions in Exchange plans were for specialty medications, compared to 0.75% in commercial health plans, a 47% difference. Increased volume for higher cost specialty drugs can have a significant impact on the cost burden for both plan sponsors and patients. As reported in our 2013 Drug Trend Report, despite comprising less than 1% of all U.S. prescriptions, specialty medications now account for more than a quarter of the country’s total pharmacy spend.

In total spend, six of the top 10 costliest medications used by Exchange enrollees have been specialty drugs. In commercial health plans, only four of the top 10 costliest medications were specialty.

Top 10 Costliest Therapy Classes 

Additional Key Insights

  • More than six in every 1,000 prescriptions in the Exchange plans were for a medication to treat HIV. This proportion is nearly four times higher in Exchange plans than in commercial health plans.
  • Approximately 43% of Exchange enrollees were previously enrolled in a plan with Express Scripts in 2013. The remaining 57% could have been uninsured or previously enrolled in a plan with pharmacy coverage administered by another organization.
  • The top 10 therapy classes by claims volume for Exchange enrollees and those in a commercial health plan were largely similar, with a few notable exceptions:

Top Conditions by Claims Volume

  • The proportion of pain medication was 35% higher in Exchange plans
  • The proportion of anti-seizure medications was 27% higher in Exchange plans
  • The proportion of antidepressants was 14% higher in Exchange plans
  • The proportion of contraceptives was 31% lower in Exchange plans

What Does This Mean for Exchange Patients and Plans?

This early analysis suggests this new benefit is providing patients with access to the medication they need.  However, in order to keep this sustainable and affordable for payers and patients, it’s important to look at the dynamics around deductibles and out-of-pocket maximums, so each group can plan accordingly.

According to the analysis, patients in Exchange plans paid a greater percentage of their pharmacy costs in the first two months of their plan, compared to those enrolled in commercial plans. As a result, health insurers’ per-member pharmacy costs so far this year are nearly 35% higher for their commercial plans vs. their Exchange plans.

We will also be keeping a close eye on cost-shifting and use of the higher-cost tiers for specialty medications and nonpreferred drugs, measuring how quickly these Exchange enrollees are meeting their out-of-pocket caps, at which point all costs will be on the health insurer. Continued reporting and insights on patient behavior and medication utilization in the Exchanges will help our clients provide a competitive, affordable benefit amid the persistent uncertainty common with a new market.

About the Analysis

The analysis is based on a national sample of more than 650,000 de-identified pharmacy claims from Jan. 1, 2014 through Feb. 28, 2014 for patients enrolled in a Public Health Insurance Exchange plan with pharmacy benefit coverage administered by Express Scripts. The analysis compared these pharmacy claims to those from commercial health plans, with pharmacy coverage administered by Express Scripts, during the same time period. The Exchange sample included approximately 423,000 lives.

Author Bio

Julie Huppert
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