2019 Drug Trend Report


The Drug Trend Report is our comprehensive analysis of usage and costs for the medications that Americans took to get and stay healthy during the past year.



2019 in review
Driving affordability for patients and sustainability for plans

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.

Focusing on patient care for better health and savings
Mother and daughter making breakfast
2.3% 2.3%
trend for commercial plans managed by Express Scripts, in line with the Consumer Price Index
1.2% 1.2%
trend for commercial plans participating in at least one of our SafeGuardRx® programs
-4.8% -4.8%
trend for tightly managed commercial plans with at least three of our solutions2

Drug trend for commercial plans managed by Express Scripts, 2019

$49.5B $49.5B
saved for patients and plans through our clinical solutions
37% 37%
of commercial plans experienced a decrease in drug spending

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

61,000 61,000
ER visits and hospitalizations avoided by plans in our RationalMed® safety program, saving lives and $1,723 per patient annually
21.6% 21.6%
more high-risk patients added statin therapy for plans participating in Diabetes Care Value℠
25,000+ 25,000+
heart attacks that could be avoided over the next 10 years if all plans participated in Diabetes Care Value
Improving care and affordability for rare and specialty conditions
Specialty patient gets help with infusion from nurse
Patients using our Accredo specialty pharmacy were 60% more likely to be adherent to biologic disease-modifying anti-rheumatic drugs (DMARDs) than those using a retail pharmacy
specialty icon
18.7% fewer people living with rare conditions had gaps between medication refills with our MitiGap solution, improving adherence to therapy
The duration of medication refill gaps for people living with rare conditions was reduced by an average of 12.6 days
-5.2% -5.2%
trend for participating plans in our SaveonSP® specialty patient assistance solution vs. 12.3% for nonparticipating plans
Helping make an impact on the opioid crisis
Man with a cast
57% 57%
reduction in average days’ supply per claim for first-time opioid users in plans enrolled in our Advanced Opioid Management℠ program

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.

17.4M 17.4M
people enrolled in plans using AOM to help protect against the potential dangers of opioid misuse and abuse – 34.7% more than in 2018
1.9M 1.9M
days’ worth of opioid medications that enrolled plans prevented from being dispensed
1.8M+ 1.8M+
interventions for at-risk people taking opioids, including consultations with neuroscience specialist pharmacists, conducted as part of AOM
Delivering care to members wherever they are
Girl in tent
15 15
solutions approved for our Digital Health Formulary, greatly simplifying the landscape for patients and payers

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.

1/3 1/3
more patients were adherent to asthma controller medication when engaged with pulmonary remote monitoring in 2019
10% 10%
decline in average blood glucose levels among patients with high levels when engaged with diabetes remote monitoring in 2019
2019 by the numbers
2.3% 2.3%
trend for commercial plans in 2019, driven by a 1.4% increase in utilization and a 0.9% rise in unit cost

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%
<1% <1%
increase in unit cost for commercial plans, even as list prices for brand drugs jumped 5.2%

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

inflammatory conditions icon
INFLAMMATORY CONDITIONS: 17.1% spending increase for drugs used to treat rheumatoid arthritis, psoriasis and other auto-immune conditions was driven by shift to newer, more expensive brand alternatives, for which there are no available biosimilars
oncology icon
ONCOLOGY: Drugs to treat multiple myeloma, certain types of lymphoma, and breast and lung cancers contributed to 7.2% higher unit cost and 3.6% higher utilization
DIABETES: 5.2% increase in spending was influenced primarily by 3.2% higher utilization for commonly used generics
HIV: Higher utilization and unit costs for newly approved brand drugs and pre-exposure prophylaxis (PrEP) therapy drove 8.1% spending increase

Trend relief

pain and inflammation icon
PAIN AND INFLAMMATION: 15.5% reduction in unit cost contributed to 18.8% decline in spending
ASTHMA: Sharp unit cost declines for brand drugs led to 15.6% lower overall spending
Antidepressants icon
ANTIDEPRESSANTS: 10% unit cost decrease was influenced by continued price reductions for generics
high cholesterol icon
HIGH CHOLESTEROL: 9.4% decline in drug spending reflected 11.9% reduction in unit cost, including 46.7% lower prices for PCSK9s inhibitors

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

$11.75 $11.75
member average out-of-pocket cost per 30-day Rx in 2019, only 19¢ or 1.6% more than in 2018
Trend overview by plan type
Utilization trend
1.4% 1.4%
Unit cost trend
0.9% 0.9%
Total trend
2.3% 2.3%

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

A vision for 2020 and beyond
Trend forecast: What could drive drug spending for the next 3 years?

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.

Industry-first solutions to help people live healthier lives

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.

>> Download Executive Summary and Public Policy Analysis

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

See previous reports

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.

See Previous Reports

About the report


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.