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 released by Express Scripts.

In total spend, six of the top 10 costliest medications used by public exchange enrollees have been specialty drugs. In commercial health plans, only four of the top 10 costliest medications were specialty. Approximately 1.1% of total prescriptions in public exchange plans were for specialty medications, compared to 0.75% in commercial health plans. 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. 

Other key findings include:

  • More than six in every 1,000 prescriptions in the public 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% 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.
  • 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% 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 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,” said Julie Huppert, vice president of health care reform with Express Scripts.
The analysis 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.

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