Express Scripts Provides First Look at 2015 Public Exchange Pharmacy Trends

- Latest Express Scripts Exchange Pulse Report reveals new exchange enrollees in Q1 2015 were healthier and spent less on medications compared to exchange enrollees in Q1 2014, helping plans better balance their risk.

- Full-year analysis of exchange plan specialty pharmacy spending reveals 24 percent growth - nearly three times the growth rate seen among traditional health plans.

- Five percent of exchange plan patients with high annual medication costs accounted for 68 percent of total pharmacy spend.

Jul 01, 2015, 07:00 ET from Express Scripts

ST. LOUIS, July 1, 2015 /PRNewswire/ -- New exchange plan enrollees spent less on medications in the first quarter of 2015 compared to the same time a year ago, according to the third edition of the Express Scripts (NASDAQ: ESRX) Exchange Pulse™ report, released today.

When compared to the first quarter of 2014, the number of new exchange plan enrollees who used at least one prescription medication declined 18 percent in the first quarter of 2015. However, when evaluating exchange plan medication trends between March 31, 2014 and March 31, 2015, researchers found that spending on high-cost specialty medications grew 24 percent – compared to eight percent growth in traditional health plans – largely attributable to hepatitis C medications, the third costliest therapy class among exchange plans.

"While it is encouraging to see data that suggests healthier Americans are enrolling in exchange plans, the research reminds us that many of these patients use this benefit to manage serious, chronic illnesses," said Julie Huppert, vice president, healthcare reform at Express Scripts. "Exchange plans have an opportunity to make medications more affordable and accessible by more closely managing the benefit, encouraging the use of home delivery pharmacy and other proven clinical pharmacy programs, which can help boost medication adherence and foster better disease management."

The Express Scripts Exchange Pulse report compares prescription medication use among exchange plan enrollees to those who are enrolled in a traditional health plan benefit. The analysis examined medication trends from January 1, 2014 to March 31, 2015, and also compared trends in Q1 2015 to those seen in Q1 2014. The analysis is based on more than 100 million de-identified pharmacy claims administered by Express Scripts during these periods.

New Trends Emerge in 2015 In addition to reduced medication use, new exchange enrollees in Q1 2015 were younger and healthier with 34 percent fewer adjusted specialty pharmacy claims than enrollees in Q1 2014. This resulted in Q1 2015 exchange enrollees spending 21 percent less out-of-pocket overall on medications, and 20 percent less out-of-pocket on specialty medications compared to Q1 2014. In addition, exchange plan costs were 36 percent lower per member per month in Q1 2015 compared to Q1 2014.

Additional key trends seen in Q1 2015:

  • Spending on hepatitis C medication increased 96 percent compared to Q1 2014.
  • Oral contraceptive use increased 29 percent, likely due to the younger average age of exchange enrollees in Q1 2015.
  • While still the most common specialty condition, particularly among enrollees ages 18 to 64, HIV prevalence declined 11 percent compared to Q1 2014. 

"While high-cost specialty medication use in exchange plans grew significantly throughout 2014, we may be seeing the start of a new chapter with this program, where healthier Americans who use fewer prescription medications are engaging with these plans," said Huppert. "If these trends continue, plans can achieve a more balanced risk pool, which will help them sustain benefit offerings in the future."

Specialty Medication Spend is Significant Data from the 15-month analysis shows specialty medications accounted for 42 percent of all pharmacy spending among exchange plans. Nearly 53 percent of exchange plan specialty pharmacy claims were for HIV, compared to 20 percent for traditional health plans. In addition, exchange plan costs were 16 percent higher per member per month compared to traditional health plans, largely due to increased specialty drug spending among exchange plan enrollees.

High-cost hepatitis C drugs Harvoni® (ledipasvir/sofosbuvir) and Sovaldi® (sofosbuvir) were the two most expensive specialty drugs for exchange plan members. Harvoni, which came to market in October 2014, represented 6.4 percent of the total pharmacy spend among exchange plans. Plans that implemented Express Scripts hepatitis C value program can expect reduced spending in this class in 2015.

Exchange Plans are Paying the Majority of Costs for Patients in High-Cost Populations There were a higher proportion of patients with high annual medication costs in exchange plans. In 2014, just five percent of exchange plan patients accounted for more than 68 percent of total prescription drug spending. In addition, the proportion of exchange plan patients with 2014 annual medication costs exceeding $50,000 was nearly two times more than commercially insured patients, and more than three times more than Medicaid patients.

Exchange plan patients with more than $50,000 in 2014 annual medications costs paid 2.2 percent of the costs of their medications out-of-pocket in 2014, and exchange plan patients with annual medications costs at or exceeding $100,000 in 2014 paid 1.7 percent of their total costs out-of-pocket. Their plans covered the remainder of the costs.

Medication Non-Adherence a Concern for Exchanges Medication non-adherence affects both exchange and traditional health plan patients; however, early data suggest that across most traditional and specialty therapy classes, medication non-adherence was higher in exchange plans compared to traditional health plans:

  • Medication non-adherence was high in four of the top 10 costliest conditions for exchange plans: diabetes, high blood pressure, hepatitis C and HIV.
  • 34 percent of exchange plan patients with high blood pressure – the most prevalent traditional condition on the exchanges – were non-adherent to medication therapy, compared to 29 percent among traditional health plan patients.
  • 27 percent of exchange plan patients treated for HIV – the most prevalent specialty condition among exchange plans – were non-adherent to medication therapy, compared to 25 percent of health plan patients.

For more information about these findings, please visit:

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 our 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 makes the use of prescription drugs safer and more affordable, managing more than one billion prescriptions each year for tens of millions of patients. On behalf of our clients – employers, health plans, unions and government health programs – Express Scripts brings the best value, high-quality service and specialized, clinical care to those we serve.

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. Express Scripts also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.

For more information about Express Scripts, visit or follow @ExpressScripts on Twitter.

MEDIA CONTACT: Jennifer Luddy (201) 269-6402

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SOURCE Express Scripts