Report sheds light on how exchange members use pharmacy benefits

Last year, Prime served more than 1.4 million public exchange members. Using data from the first full year of the public exchanges, Prime identified drug usage and cost trends. This data gives us perspective on what the future holds for these members. It also gives us insight on what that might mean for Prime in this market.

The report compares 13 million public exchange member pharmacy claims against more than 143 million commercial member pharmacy claims administered by Prime in 2014. This analysis shows that public exchange members had slightly higher per member per month drug costs versus commercial members. This was due to a heavier use of high-cost specialty medications like Sovaldi® and Harvoni®. Our analysis also found that public exchange members:

  • Filled an average of 11.7 prescriptions per member per year. This exceeded commercial member fills by 13.6 percent.
  • Had a 16.4 percent higher spend on specialty medications.
  • Were 2.5 times more likely to have hepatitis C or HIV. This caused an almost 200 percent higher spend on related medicines.

“We entered the first year of public health exchanges like others in our industry – with many unanswerable questions,” said Michael Showalter, Prime’s senior vice president and chief marketing officer, “This report confirms our initial expectations that public exchange members would be, on average, older and have more health care needs than our commercially insured members. Having this full year data will help us better serve our members and clients.”

The report closes with thoughts from Prime’s leaders on what the future holds for public exchanges. They note Prime’s 2015 growth in this market and how that compares to the national public exchange enrollment numbers. They also talk about legal uncertainties and market trends that may influence the success of the exchanges in the future.

Access the full report here.

blog comments powered by Disqus