2019 Drug Trend Report
2019 gave us “Old Town Road,” Baby Yoda and a thrilling Women’s World Cup victory for Team USA. In the world of pharmacy, 49 drugs entered the market,1 including the gene therapy Zolgensma®, the most expensive single-dose drug ever, with a list price of $2.1 million!
Faced with these and other challenges to sustainable care, Express Scripts introduced several industry-first solutions in 2019, including the Patient Assurance Program℠, Embarc Benefit Protection℠ and Digital Health Formulary. Together, they bring the promise of simplicity, predictability and, above all, affordability to high-priced insulin, gene therapies and the emerging world of digital health – for 2020 and beyond.
Most importantly, our focus on patient care delivered better health and savings for patients and plans in 2019, as we:
- Saved patients and plans nearly $50 billion through our clinical solutions
- Kept the overall rate of increase in drug spending to just 2.3%, in line with the Consumer Price Index
- Drove a decrease in drug spending for more than one-third of our commercial plans
- Helped reduce drug spending by 4.8% for tightly managed commercial plans2
- Held average member out-of-pocket costs for a 30-day Rx to $11.75, just a 19¢ or 1.6% increase from 2018, despite a 5.2% increase in list prices for brand drugs
Scroll down for these and other data insights. And be sure to download our two-page Executive Summary and our 2020 Public Policy Analysis.
Trend = Year-over-year percent change in per-member-per-year (PMPY) spending on prescription drugs, inclusive of self-administered specialty drugs paid under the pharmacy benefit.
Drug trend for commercial plans managed by Express Scripts, 2019
Plans participating in our SafeGuardRx programs had lower spending in managed therapy classes vs. nonparticipating plans
Since 2015, our SafeGuardRx platform has helped improve care and affordability for patients with the toughest medical conditions and their plans. In 2019, participating plans, covering more than 46.9 million Americans, saw better care and lower spending than nonparticipating plans across every therapy class covered by SafeGuardRx programs, including Rare Conditions Care Value℠, which launched last year.
Trend for participating/nonparticipating plans in SafeGuardRx programs by therapy class, 2019
Double-digit declines in opioid use in each of the past 3 years
Launched in 2017, Advanced Opioid Management (AOM) has proven successful in helping enrolled plans keep opioid prescriptions to 7 days or less for 96.5% of patients. Opioid utilization for those plans dropped 15.2% in 2019, on top of reductions of 16.6% in 2018 and 10.3% in 2017.
Case study: The proven value of remote monitoring solutions
Patients in a prior study who had their asthma monitored remotely by pulmonary pharmacists from our Therapeutic Resource Center℠ saw an 80% reduction in the daily use of their rescue medications and a concomitant increase in use of their controller medications vs. those who didn’t participate in remote monitoring.
Trend = Year-over-year percent change in per-member-per-year (PMPY) spending on prescription drugs, inclusive of self-administered specialty drugs paid under the pharmacy benefit.
Less than 3% for 3
Despite continuing increases in drug prices and new million-dollar therapies, Express Scripts has kept annual spending increases for prescription drugs below 3% for the past 3 years – at or lower than the Consumer Price Index.
Drug trend for commercial plans managed by Express Scripts, 2017-2019
Less than 3% for 3
Despite continuing increases in drug prices and new million-dollar therapies, Express Scripts has kept annual spending increases for prescription drugs below 3% for the past 3 years – at or lower than the Consumer Price Index.
Drug trend for commercial plans managed by Express Scripts, 2017-2019
| 2017 | 2018 | 2019 | |
|---|---|---|---|
| Utilization trend | 0.7% | 0.8% | 1.4% |
| Unit cost trend | 0.8% | -0.4% | 0.9% |
| Total trend | 1.5% | 0.4% | 2.3% |
Prices for brand drugs rose 4x the rate of common household goods over 6 years
From Jan. 2014 through Dec. 2019, the most commonly used brand drugs experienced list price inflation of 70.5%. In contrast, a market basket of commonly used household goods rose only 9.9%, and prices for the most commonly used generic medications declined 40.9%.
Express Scripts prescription price index, 2014-2019
Trend pressure
Trend relief
Specialty drugs accounted for greater share of total spend than in 2018
Although specialty drugs are used by only 2% of the population, its share of spend jumped from 44.7% in 2018 to 47.7% in 2019, nearly half of all spending on prescription drugs. This was due to new therapies entering the market with few or no competing drugs to drive down prices.
Percent of total drug spend by drug type, 2019
Patient share of costs increased very slightly in 2019
Even as brand drug list prices increased 5.2%, the share of costs paid by patients went up only slightly from 15% in 2018 to 15.1% in 2019. At $11.75 for a 30-day supply, member average out-of-pocket costs increased only 19¢ or 1.6%.
Percent of total pharmacy costs paid by patients and plans, 2019
Top 15 therapy classes for commercial plans
By PMPY spend, 2019
Components of commercial trend for top 15 therapy classes
By PMPY spend, 2019
| PMPY | Trend | |||||
|---|---|---|---|---|---|---|
| Therapy class | Spend | Adjusted RXs | Utilization | Unit cost | Total | |
| 1. | Inflammatory conditions | $198.54 | 0.10 | 6.1% | 11.0% | 17.1% |
| 2. | Diabetes | $116.72 | 0.98 | 3.2% | 2.0% | 5.2% |
| 3. | Oncology | $85.59 | 0.05 | 3.6% | 7.2% | 10.8% |
| 4. | HIV | $52.49 | 0.03 | 3.5% | 4.6% | 8.1% |
| 5. | Multiple sclerosis | $50.70 | 0.01 | -12.1% | 4.7% | -7.4% |
| 6. | Pain/inflammation | $31.34 | 0.89 | -3.3% | -15.5% | -18.8% |
| 7. | Attention disorders | $30.10 | 0.27 | 3.4% | -8.3% | -4.9% |
| 8. | Asthma | $23.59 | 0.45 | 2.0% | -17.6% | -15.6% |
| 9. | High blood pressure/heart disease | $23.50 | 2.40 | 1.8% | -8.7% | -6.9% |
| 10. | Skin conditions | $22.91 | 0.14 | 3.4% | 5.6% | 9.0% |
| 11. | Depression | $21.58 | 1.07 | 5.4% | -10.0% | -4.6% |
| 12. | Anticoagulants | $19.97 | 0.09 | 4.3% | 7.0% | 11.3% |
| 13. | Contraceptives | $17.33 | 0.61 | 0.3% | -10.8% | -10.5% |
| 14. | Seizures | $17.04 | 0.23 | -0.3% | -6.0% | -6.3% |
| 15. | High blood cholesterol | $16.80 | 1.05 | 2.5% | -11.9% | -9.4% |
| All other classes | $303.82 | 4.92 | 0.1% | -1.0% | -0.9% | |
| Total for all therapy classes | $1,032.02 | 13.29 | 1.4% | 0.9% | 2.3% | |
See the top contributors to trend for each plan type
Inflammatory conditions: New formulations for drugs to treat ulcerative colitis and new medications for atopic dermatitis may impact the market in 2020.
Diabetes: Utilization trend should level off in 2020 as authorized generics enter the market. Total trend could rise slightly, reflecting higher drug prices, as insulins are considered biologics from March 2020.
Oncology: Trend could be up slightly in 2020 due to increased utilization and pricing of oral drugs, such as Ibrance® (palbociclib). Generics for Pomalyst® (pomalidomide) and Sutent® (sunitinib malate) should drive trend down in 2021; however, inflation and growing utilization may increase it again in 2022.
HIV: In 2020, generics for Selzentry® (maraviroc) and Truvada® (emtricitabine-tenofovir) are expected to lower unit cost trend, while utilization rates should increase.
Multiple sclerosis: During 2020, top drugs such as Gilenya® (fingolimod), Tecfidera® (dimethyl fumarate) and Ocrevus® (ocrelizumab) will face competition, causing declines in unit cost that could spill over into 2021. After that, two more brands are expected to gain FDA approval, driving unit cost trend up in 2022 as utilization steadily increases.
Pain/inflammation: With multiple generics launched in 2019, reduced unit cost trend is likely in 2020. That's on top of lower utilization due to concerns around opioid abuse. In 2021 and 2022, unit cost trend could stabilize but negative overall trend should continue.
Anticoagulants: Utilization is estimated to increase steadily while unit cost trend slowly begins to decline by 2022. Multiple generics for Pradaxa® (dabigatran etexilate) are expected toward the end of 2021, helping to reduce unit cost trend into 2022.
Gastronintestinal disorders: In 2020, trend could be influenced by small numbers of very costly non-alcoholic steatohepatitis drugs, including obeticholic acid and elafibranor. In 2021 and 2022, several others may follow, including cenicriviroc and pegbelferming, driving high unit cost trend.
For estimated trend data and other details, please contact your Express Scripts account or sales team.
Looking ahead to the next decade, Express Scripts remains committed to delivering care that’s simpler and more affordable for patients and payers. We’re personalizing health services to help people live healthier lives through breakthrough solutions like these:
Patient Assurance ProgramSM ensures that every person living with diabetes who needs insulin pays no more than $25 per 30-day supply – even for brands that cost hundreds of dollars per prescription.
Embarc Benefit ProtectionSM makes the costliest therapies, including gene therapy, more affordable for the patients who need them and the plans that cover them.
Digital Health Formulary helps patients take better control of their health and eliminates the burden of evaluating thousands of digital health solutions on the market.
Health Connect 360SM promotes improved outcomes by helping to close gaps and coordinate care across a patient’s entire health care team for more than a dozen chronic conditions.
2019 Executive Summary
Two-page summary of key findings from the 2019 Drug Trend Report
2020 Public Policy Analysis
Companion report focusing on our U.S drug pricing policy recommendations
Since the first Drug Trend Report in 1997, we've continued to provide the trend data and insights payers need to provide high-quality care to their members and manage costs.
Methodology
For the 2019 Drug Trend Report, we analyzed one of the broadest cohorts in the industry – prescription drug use data of 33.6 million members with a pharmacy benefit plan administered by Express Scripts.3 The plan sponsors providing the pharmacy benefit paid at least some portion of the cost for the prescriptions dispensed to their members, providing what is known as a funded benefit.
Both traditional and specialty drugs are included within each therapy class. Specialty medications include injectable and non-injectable drugs typically used to treat chronic, complex conditions. Specialty drugs may have one or more of the following qualities: frequent dosing adjustments, intensive clinical monitoring, intensive patient training and compliance assistance, limited distribution, and specialized handling or administration.
Nonprescription medications (except for diabetic supplies billed under the pharmacy benefit), vaccines, prescriptions that were dispensed in hospitals, long-term care facilities, and other institutional settings, and medications billed under the medical benefit at any time in 2018 or 2019 were excluded.
Trend and other measures were calculated separately for those members with commercial insurance coverage. Members used Express Scripts for retail and home-delivery pharmacy services; they used Accredo, the Express Scripts specialty pharmacy, for specialty drug prescriptions.
Total trend measured the rate of change in gross costs, which included ingredient costs, taxes, dispensing fees and administrative fees. Gross cost does not exclude member cost share, and it is net of rebates adjusted for other pharmaceutical reimbursements.
Total trend comprised utilization trend and unit cost trend. Utilization trend was defined as the rate of change in total days’ supply of medication per member, across prescriptions. Unit cost trend was defined as the rate of change in costs due to inflation, discounts, drug mix and member cost. Utilization and cost were determined on a per-member-per-year (PMPY) basis.
Metrics were calculated by dividing totals by the total number of member-months (which was determined by adding the number of months of eligibility for all members in the sample) multiplied by the number of months per period.
The Express Scripts Prescription Price Index (PPI) measures inflation in prescription drug prices by monitoring changes in list prices for a fixed market basket of commonly used prescription drugs. Separate market baskets, which were defined for brand drugs and for generic drugs, were based on the top 80% of utilized drugs, starting in 2014. The Specialty PPI used the same methodology, but it was limited to specialty therapies, starting with 80% of the most commonly used brand and 100% of generic specialty medications.
Please note: Although up to nine decimal places were allowed in making all calculations, in most cases the results were rounded down to one or two decimals for easier reading. Therefore, dollar and percentage calculations may vary slightly due to rounding.
Explore related insights
2. Enrolled in ScreenRx®, at least one SafeGuardRx® program and Advanced Utilization Management.
3. Plan sponsors were excluded if they were not Express Scripts clients in both 2018 and 2019; or if they had less than 12 months of claims data in either year, 100% or 0% copayment benefits, or eligibility shifts exceeding 20% for commercial plans (eligibility shifts exceeding 50% for Medicare and Medicaid plans). Plan sponsors contractually prohibited from inclusion also were excluded. Individual members might be covered, and thus included, for only a portion of the time periods of interest.