PBM Reports High Usage of HIV, HCV Drugs Among ACA Clients

A claims data sample from Express Scripts shows that patients enrolling for health coverage under the Affordable Care Act (ACA) are more likely to use specialty drugs to treat HIV/AIDS or hepatitis C than those with coverage through employers. The results, which cover claims from the first 2 months of 2014, were reported April 9, 2014, by MedCity News.1

Experts noted that the results do not reflect late enrollment that caused the ranks signing up on state and federal exchanges to swell past 7 million, the original target for ACA enrollment from the Congressional Budget Office. Enrollment on the exchanges through the end of January was only 3.3 million, as reported by the US Department of Health and Human Services.2

It was no surprise that those with chronic conditions enrolled as early as possible, with younger, healthier consumers signing up closer to the deadline. “We all expected that the people who signed up by January and February would be a lot sicker than anyone else,” said Robert Lazsewski, a consultant to the insurance industry. “It will be a year before we know what we’ve got.”1

Express Scripts, one of the nation’s largest pharmacy benefit managers, analyzed more than 650,000 claims filed in January and February with 25 insurers, and compared them to claims filed by a subset of employer-based plans that Express Scripts oversees.

The analysis was based on total drug spending, including the portion paid by insurers and patients. Among the findings:

• HIV drugs accounted for more than 6 in every 1000 prescriptions, a rate 4 times that of employer plans.

• Sovaldi, an $84,000 treatment approved in December to treat hepatitis C, came in second for total spending, while it ranked eighth in the comparison group.