The Employer's Guide Blog for Overseeing PBMs

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Early Pharmacy Claims Data from Exchange Enrollees Indicate High Usage

When setting rates for qualified health plans sold through public exchanges a year ago, actuaries anticipated that people who purchased coverage through an exchange would be older and less healthy than the commercially insured population. They also assumed there would be pent-up demand for pharmaceuticals and care. 

Now that exchanges are up and running, preliminary drug claims data is showing such a trend. The April 17 issue of Atlantic Information Services, Inc.’s Inside Health Insurance Exchanges (HEX) walks readers through data from two pharmacy benefit managers (PBMs) and what it means for insurers.

During the first two months of 2014, exchange enrollees were more likely to use costly specialty drugs when compared to those with coverage outside of the exchanges, according to preliminary claims data released April 9 by Express Scripts. 

According to the early data, six of the 10 costliest medications used by exchange enrollees were specialty drugs versus four of the top 10 used by commercial health plan enrollees. Of total prescriptions filled for exchange plans, 1.1% was for specialty drugs, compared with 0.75% in commercial plans — a near-50% difference.

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Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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