The company found that for every $1 exchange enrollees spent on prescriptions, $0.38 went toward high-cost specialty drugs even though specialty drugs represent just a sliver (1.3%) of total pharmacy claims. Hepatitis C medication Sovaldi and HIV drug Atripla were among the costliest specialty drugs.
Julie Huppert, vice president of healthcare reform at Express Scripts, said in an interview that the people who first signed up for coverage under the Patient Protection and Affordable Care Act often were in the sickest subgroup. Some didn't have insurance because they were denied access or couldn't afford it because of pre-existing conditions like HIV. But once people bought ACA plans, they raced to get medications they previously couldn't get as premium and cost-sharing subsidies made specialty drugs more accessible.
“It makes getting treatment for costly conditions like HIV more affordable to them,” Huppert said.
More recent exchange enrollees, or those who signed up for ACA plans after March 1, were generally healthier than the first wave. Huppert expects younger, healthier consumers will eventually even out the marketplace. But it's likely ACA enrollees will continue to fill higher volumes for specialty pharmaceuticals than those with employer-sponsored insurance.
“You will continue to see probably a higher prevalence of the specialty conditions in the health exchange marketplaces,” Huppert said. “But I think you'll see the risk profile level off over time.”
HIV was the top specialty condition among the exchange population. In all, 3 out of 5 specialty claims are for HIV drugs. And people with HIV were much more likely to need medication for hepatitis C, hepatitis B and non-HIV viral infections.
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