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Increased utilization driving pharmacy spend in exchange plans


Express Scripts Exchange Pulse report found that utilization, particularly for traditional meds, was one of the biggest factors driving spending in 2015, accounting for more than half of the exchange plans $99 PMPY increase in spending between 2014 and 2015.

There’s a lot more runway for increased spending on traditional medications on exchange plans, according to a new report.

Express Scripts Exchange Pulse report found that utilization, particularly for traditional medications, was one of the biggest factors driving spending in 2015, accounting for more than half of the exchange plans $99 per member per year (PMPY) increase in spending between 2014 and 2015.


"Yet despite representing a majority of the spending increase, spending on traditional medications still lags the traditional medication spending of commercially insured plans by 31%," according to Julie Huppert, vice president Healthcare Reform, Express Scripts. "Plans should prepare for continued growth in the use of traditional medications as more enrollees learn how to use their benefit and begin to seek medical care."

In addition, HIV and hepatitis C remain the costliest specialty categories, but spending is beginning to normalize.

"When the exchanges first opened, enrollees who were unqualified for health coverage due to a pre-existing condition began to use their new benefit immediately, causing an initial surge in the use of medications for HIV and hepatitis C," Huppert says. "While those two conditions still lead specialty spending, the population of enrollees with other chronic conditions is beginning to grow, mirroring trends we see in commercial prescription medication use."

Specifically, diabetes and inflammatory conditions, the top two costliest therapy classes for commercial plans, are the third and fourth costliest classes for exchange plans, according to the report.

Silver plan prescription spending grew the fastest over the past two years. Platinum- and gold-level plans, favored by enrollees with costly chronic conditions, had higher overall drug spend. However, silver plans, the most popular metal level plan in the exchanges, saw the greatest spending growth. As more enrollees began using their benefit, silver plans saw a 20.5% increase between 2014 and 2015.

"Such a jump is yet another signal that the majority of exchange enrollees are becoming more comfortable with their benefit and will begin using it more," Huppert says.

Utilizing access to approximately one-third of all U.S public exchange members, the Express Scripts Exchange Pulse Report compares year-over-year trends in prescription medication use among the exchange plan enrollees to those enrolled in a commercial health plan, between 2014 and 2015.

Next: Words of wisdom



Based on the report, Huppert offers this:

• Drive down costs so you can lower premiums.

"Formulary, utilization and channel management tools can mitigate increases in medication use by ensuring patients receive the right drug at the right cost, and at the most cost-effective dispensing channel," she says. 

• Focus on the growing therapy classes, particularly in specialty.

"As the population of patients with other specialty conditions continues to grow, plans will need to closely manage their specialty pharmacy benefit, leveraging medical benefit management and other strategies, along with condition-specific, personalized pharmacy care," Huppert says.

• Enhance member care.

A population new to healthcare coverage should be surrounded with care to ensure proper medication use and reduce waste, according to Huppert.

"Educating patients, coordinating care and encouraging medication adherence, like our pharmacists do in our Therapeutic Resource Centers, delivers better health outcomes and helps create a positive healthcare experience, which can go a long way to creating the type of plan loyalty we see in Medicare plans."

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