Express Scripts Analysis Reveals First Look at Medication Utilization Trends Among Public Health Insurance Exchange Enrollees

Early Data Shows Greater Use of Specialty Medications in Exchange Plans vs. Commercial Health Plans

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Apr 09, 2014, 08:00 ET

ORLANDO, Fla., April 9, 2014 /PRNewswire/ -- In a first look at pharmacy trends in Public Health Insurance Exchange plans, use of specialty medications was greater among Exchange enrollees versus patients enrolled in a commercial health plan, according to new research presented today by Express Scripts (NASDAQ: ESRX).

"This is a very early analysis that starts to tell the story of how Exchange enrollees are using this new benefit," said Julie Huppert, Express Scripts vice president of healthcare reform. "Our initial insights provide an important benchmark for Exchange plans, and help identify areas where Express Scripts and health insurers can provide greater clinical support for patients with chronic and complex conditions to ensure these patients experience the best possible health outcomes."

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. Approximately 1.1 percent of total prescriptions in Exchange plans were for specialty medications, compared to 0.75 percent in commercial health plans. Increased volume for higher cost specialty drugs can have a significant impact on the cost burden for both plan sponsors and patients. Despite comprising less than one percent of all U.S. prescriptions, specialty medications now account for more than a quarter of the country's total pharmacy spend.

The analysis, presented today at the Express Scripts Outcomes Symposium in Orlando, is based on a national sample of more than 650,000 de-identified pharmacy claims from January 1, 2014 through February 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.

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.
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:
- The proportion of pain medication was 35 percent higher in Exchange plans.
- The proportion of anti-seizure medications was 27 percent higher in Exchange plans.
- The proportion of antidepressants was 14 percent higher in Exchange plans.
- The proportion of contraceptives was 31 percent lower in Exchange plans.
Approximately 43 percent of Exchange enrollees were previously enrolled in a plan with Express Scripts in 2013. The remaining 57 percent could have been uninsured or previously enrolled in a plan with pharmacy coverage administered by another organization.
Patients in Exchange plans in the first two months paid a greater percentage of their pharmacy costs compared to those enrolled in commercial plans. As a result, health insurers' per-member pharmacy costs so far this year are nearly 35 percent higher for their commercial plans vs. their Exchange plans.

"We are keeping a close eye on cost-shifting and use of the higher-cost tiers for specialty medications and non-preferred 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," said Huppert. "Our 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 regulated market."

For more information about these findings, please visit http://lab.express-scripts.com/insights/government-programs/first-look-health-exchange-medication-utilization.

About Express Scripts Government Programs

Express Scripts has more than a decade of proven experience and deep capabilities providing pharmacy benefit management services to plan sponsors working in regulated healthcare markets. Express Scripts' Government Programs employees are dedicated to serving Medicare, Medicaid and public exchange marketplace plans and members. Regulated-markets clients benefit from Express Scripts' unmatched compliance rigor, consultative partnership and clinical care innovations. Express Scripts offers Medicare, Medicaid and public exchange clients a wide range of innovative products and consultative solutions that deliver a more tightly managed, cost effective benefit while improving healthcare quality for those we serve.

About Express Scripts

Express Scripts manages more than a billion prescriptions each year for tens of millions of patients. On behalf of our clients — employers, health plans, unions and government health programs — we make the use of prescription drugs safer and more affordable. Express Scripts uniquely combines three capabilities — behavioral sciences, clinical specialization and actionable data — to create Health Decision Science℠, our innovative approach to help individuals make the best drug choices, pharmacy choices and health choices. Better decisions mean healthier outcomes.

Headquartered in St. Louis, Express Scripts provides integrated pharmacy-benefit management services, including network-pharmacy claims processing, home delivery, specialty benefit management, benefit-design consultation, drug-utilization review, formulary management, and medical and drug data analysis services. The company also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.

For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter.

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SOURCE Express Scripts