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Insights

Apr 10, 2014

Express Scripts Data Provides Early Look at Exchange Enrollee Drug Utilization

Published

Apr 10, 2014

On April 9, pharmacy benefit manager (PBM) Express Scripts released a report highlighting prescription drug utilization by enrollees in new exchange plans.

The report finds that, in January and February, exchange enrollees used specialty medications more frequently than patients enrolled in other commercial plans.  Approximately 1.1 percent of total prescriptions in exchange plans were for specialty drugs, compared with 0.75 percent of prescriptions in other commercial health plans. Although three common chronic conditions generated the most claims in both markets—hypertension/heart disease, high blood cholesterol and depression—claims volume for depression, pain and seizure medicines were greater in exchange markets. 

More than six out of every 1,000 prescriptions in exchange plans were for HIV/AIDS medicines, four times the rate in commercial plans. The study also lists the top 10 costliest medications utilized by each population, several of which are specialty drugs that treat HIV/AIDS, hepatitis C and rheumatoid arthritis.

The report notes that patients in exchange plans paid a larger portion of their pharmacy costs during the first two months of the plan year when compared with patients in other commercial plans.  This underscores the high patient cost sharing associated with exchange products given high deductibles and significant coinsurance rates for specialty medicines. 

The Express Scripts report supports early hypotheses that patients who signed up for coverage early would have greater health needs. While stakeholders largely anticipated this trend, the early data demonstrating greater use of specialty medicines among exchange enrollees could be troublesome for health plans. However, the data does not include those who signed up in March, and officials have touted significant interest among younger exchange eligibles during this period.  Nonetheless, plans are already engaged in their 2015 planning processes and will take early 2014 experience into consideration as they design products and bids for qualified health plans (QHPs).

Despite prevalence of high deductibles and high cost sharing, patients in exchange plans are accessing specialty medicines, which may reflect effective affordability support from manufacturers, foundations, or AIDS Drug Assistance Programs (ADAPs). In addition, patients with high drug spending are expected to reach out-of-pocket maximums, increasing plan liability for the remainder of the benefit year.

As additional claims data on exchange enrollees become available, plans will use such information to inform 2015 benefit and rate decisions.  Although, the timing of open enrollment and the 2015 QHP process will likely leave many plans with an incomplete picture of exchange enrollment and risk as they plan for 2015.

View Express Scripts’ full report.

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