Exchange Enrollees Use More Generics and Specialty Drugs

(with Table: Top 10 Drug Classes by Specialty Claims Volume)

Reprinted from INSIDE HEALTH INSURANCE EXCHANGES, a hard-hitting newsletter with news and strategic insights on the development and operation of public and private exchanges.

October 16, 2014 Volume 4 Issue 20

During the first seven months of 2014, nearly half of people who bought health coverage through a public exchange had at least one prescription filled, according to an analysis of 80 million prescription claims conducted by pharmacy benefit manager Express Scripts Holding Co.

And exchange enrollees also were more likely than non-exchange members to opt for a generic drug. Moreover, people who signed up for coverage on an exchange on or after March 1 were younger than those who signed up earlier. The enrollees who signed up earlier also spent more on pharmaceuticals for each of the top 10 conditions than people who enrolled later.

The report compares drug utilization within health plans sold through an insurance exchange to trends in traditionally insured populations. Express Scripts says it supports more than 2 million members who purchased health coverage through an insurance exchange — about one-third of the exchange market.

While exchange enrollees obtained medications to treat traditional chronic conditions, such as heart disease and diabetes, at rates similar to those insured individuals who did not purchase insurance on an exchanges, exchange enrollees spent significantly more on specialty pharmacy drugs (see table, below).

Pent-up demand among people who previously couldn’t afford non-subsidized health coverage, combined with those who were denied coverage due to a pre-existing condition, appears to have driven the higher specialty drug usage. “One could infer from the data that people who enrolled earlier were sicker, as many had expected,” explains Julie Huppert, Express Scripts’ vice president of health care reform.

Specialty medications used to treat HIV accounted for 56.53% of specialty claims among exchange enrollees. During the first seven months of 2014, nearly three out of every five specialty prescriptions filled by an exchange member were for an HIV medication. By contrast, HIV drugs make up 19.82% of specialty claims among people with coverage outside of an exchange.

“This group appears to have more complex, high-cost and chronic conditions compared to our traditional book of business,” Huppert tells HEX. She says community groups, caregivers and social workers likely urged HIV patients to buy insurance coverage through the exchanges.

Higher cost-sharing in exchange-based plans translated to higher pharmacy spending. According to Express Scripts’ analysis, exchange enrollees spent an average of $38.98 per member per month — about $8 more per month than people with non-exchange health coverage. “We know that most people on exchanges enrolled in a silver plan, which carries an average 30% cost-share for individuals,” Huppert explains.

“That’s generally higher than what you’d see in employer-sponsored coverage. So it’s not too surprising.”

For the 2014 plan year, the Affordable Care Act (ACA) set an out-of-pocket maximum of $6,350 per member for self-only coverage. That amount will increase to $6,600 for the 2015 plan year.

Some Enrollees Fill More Prescriptions

Here’s a look at more highlights from the report:

• Exchange enrollees between the ages of 18 and 34 fill twice as many specialty medications as those covered by other policies.
• Patients with HIV were 3.5 times more likely to take a Hepatitis C medication and 24 times more likely to take a Hepatitis B medication.
• Nearly 90% of exchange plan prescriptions filled through July were for generic medications. This generic fill rate outpaced that of the traditionally insured population by six percentage points.
• Use of contraceptives is 32% higher in traditional health plans compared to exchange-based coverage.
• Use of pain medications is 39% higher in the exchange plans when compared to other types of coverage.
  Download the report at http://tinyurl.com/l88t879.
  Top 10 Drug Classes by Specialty Claims Volume
  People who purchased coverage through an insurance exchange were nearly 60% more likely to fill prescriptions for specialty medications than were other insured individuals, according to data released Oct. 8 by Express Scripts Holding Co. Specialty pharmacy made up just 1.3% of adjusted pharmacy claims, but consumed 38% of the total pharmacy spend for exchange-based plans.

Coverage Purchased Through a Public Health Insurance Exchange
Drug Class	% of Specialty Claims
HIV	56.53%
Transplant	14.27%
Inflammatory Conditions	10.68%
Multiple Sclerosis	6.08%
Cancer	3.46%
Hepatitis C	2.95%
Anticoagulant	1.74%
Miscellaneous Specialty Conditions	0.67%
Osteoporosis	0.62%
Pulmonary Hypertension	0.54%
Non-Exchange-Based Insurance
Drug Class	% of Specialty Claims
Transplant	23.04%
Inflammatory Conditions	21.40%
HIV	19.82%
Multiple Sclerosis	11.16%
Cancer	5.37%
Anticoagulant	3.36%
Hepatitis C	2.43%
Growth Deficiency	2.24%
Infertility	1.77%
Miscellaneous Specialty Conditions	1.67%

SOURCE: Express Scripts Holding Co., “Exchange Pulse Report.” Based on a national sample representing 80 million claims. October 2014.

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