Average Number of Claims and Pharmacy Spend

I was reading a Barclay’s Capital report this morning put out by Larry Marsh and team. In it, it included some data on the PBM market. What I found interesting were two key data points:

  1. The average number of prescriptions PMPY (per member per year) by insurance type
    1. Medicare Part D uses approximately 30 Rxs PMPY
    2. Commercial uses approximately 15 Rxs PMPY
    3. Medicaid uses approximately 11 Rxs PMPY
    4. Uninsured uses approximately 5 Rxs PMPY
  2. As you might expect, the costs per member per year are also different
    1. Medicare Part D is approximately $1456 PMPY
    2. Commercial is approximately $844 PMPY
    3. Medicaid is approximately $522 PMPY
    4. Uninsured in approximately $257 PMPY

Interesting, if you look at the assumptions and data around the uninsured, they pay more per generic script than anyone else, and less (on average) per brand script. BUT, the brand script number is deceiving since they have no specialty scripts in there (since the uninsured could never afford those prices).

[Note – I use the term “approximately” since these were derived numbers based on CMS, CBO, and Barclay’s estimates.]

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