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Early Pharmacy Claims Data from Exchange Enrollees Indicate High Usage, Reports April 17 Issue of AIS Newsletter

>PRWEB.COM Newswire

Washington, DC (PRWEB) April 23, 2014

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.

Prime Therapeutics has seen similar results. Compared to its commercial book of business through February, the PBM says new individual enrollees had twice as many 90-day prescriptions as would be expected in an average commercial book of business.

"What that may mean is there was an unmet need for people with chronic illnesses to get maintenance medication," Michael Showalter, Prime's chief marketing officer, tells HEX. "From a payer perspective, that may be concerning, but it depends on how you priced for the product in the first place."

"This early glimpse is crucial for insurers as they plan to set rates for next year and may not have time to assess much more than this," says Julie Huppert, vice president of healthcare reform at Express Scripts. "To keep this sustainable and affordable for payers and patients, it's important to look at the dynamics around deductibles and out-of-pocket maxes, so each group can plan accordingly." She continues, "Since this data is only through Feb. 28, it doesn't capture the last-minute enrollees who some suspect may be younger or healthier. Future analysis will give us a better picture of what those lives look like."

Visit to read the article in its entirety, which also offers data on the number of claims per person and other details.

About Inside Health Insurance Exchanges
Inside Health Insurance Exchanges provides hard-hitting news and strategies on the details of federal, state and private health insurance exchanges, for business planners with health plans, hospitals and health systems, medical groups, ancillary providers, suppliers, pharma companies and state health policy makers. The biweekly newsletter answers questions about this cornerstone of the health reform law -- who will participate, what product designs will look like, the effect on enrollment and more. Subscribers receive reliable intelligence on how to make the most of the enormous transformation in health insurance that is about to unfold and how to succeed in the insurance marketplace of tomorrow. Visit for more information.

About AIS
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, websites, looseleafs, books, strategic reports, databases, webinars and conferences. Learn more at

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