Marketplace Enrollees Are Using Their Benefits: Express Scripts


Pharmacy benefits have already been used by nearly half of Americans enrolled in the Marketplace, according to data recently published by Express Scripts. This is the case even for those who enrolled relatively late (April 2014). The Express Scripts analysis is based on a national sample of more than 80 million de-identified pharmacy claims administered by Express Scripts between January 1, 2014 and July 31, 2014.

Express Scripts says that this pharmacy use rate is similar to the use rate of Americans with so-called “traditional” insurance (55 percent) during the same period, which is a bit surprising, since the latter are more likely to have been insured since January 2014 and are most likely more familiar with health insurance.

Consistency in the Marketplace. “It’s important to see this type of consistency in how new exchange members are using their pharmacy benefit, especially those who enrolled more recently,” said Julie Huppert, Express Scripts vice president of healthcare reform. “They are paying premiums, seeing their physicians and filling prescriptions.”

Generics and silver plans are popular. The use of generic medications outpaced that of the traditionally insured population by 6 percent, the data revealed. Through July 2014, 87 percent percent of Exchange plan prescriptions filled were for generic medications. “The Silver-rated plans—those with lower premiums but higher out-of-pockets costs for brand-name medications—have been the most popular among consumers on the Exchanges, particularly among those eligible for subsidies,” said Huppert. “By preferring generic medications over more expensive brand-name alternatives, these members are using their plans in the way they were designed.”

Differences in medications. Express Scripts also found that the use of pain medications is 39 percent higher in the Exchange plans, and the use of antidepressants is 12 percent higher. The use of contraceptives is 32 percent higher in traditional health plans, however. Both groups filled more prescriptions to treat hypertension than any other condition.

Medications to treat such chronic conditions as heart disease and diabetes are being obtained by Exchange enrollees at rates similar to other insured individuals.

Specialty medications. The Express Scripts data show that 59 percent percent more prescriptions for specialty medications are filled by Exchange enrollees than for other insured individuals, and Exchange enrollees aged 18-34 fill twice as many specialty medications than similarly aged individuals insured in a traditional health plan. This has a relatively important financial effect, because specialty medications account for 38 percent of the total pharmacy spending for the Exchange plans, despite accounting for only 1.3 percent of the number of total pharmacy claims. By comparison, Express Script points out, only 28 percent of the total pharmacy spending for traditional health plans is attributed to specialty drugs.

“Given the increased prevalence of specialty conditions, it’s vitally important for these Exchange plans to provide patients with clinical programs that ensure appropriate management of these complex, high-cost medications,” said Huppert.

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