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Use of and Spending on Top Prescription Drugs in Employer Sponsored Insurance, 2021

Recent policy and other initiatives aim to reduce spending on prescription drugs. At the federal level, the Inflation Reduction Act targets reductions in drug spending in Medicare through price negotiation, capping out-of-pocket spending by patients, and requiring drug manufacturers to pay rebates when prices rise faster than inflation. At the state level, there are initiatives to increase drug price transparency, enforce stronger regulation of various actors in the drug supply chain (e.g., pharmacy benefit managers), cap patient out-of-pocket spending, and conduct affordability reviews for drugs that exceed certain price or price growth thresholds. Outside the regulatory space, new models such as the Cost Plus Drug Company seek to offer lower drug prices, and full transparency of prices, in order to increase equitable access to drugs.

To inform policy action focused on lowering drug prices among those with commercial insurance we provide data on prescription drugs associated with the most use and the highest spending among those with employer-sponsored insurance (ESI) in HCCI's claims database in 2021. The most used drugs were relatively low-priced drugs used for chronic disease management, including drugs to treat high cholesterol, hypertension, diabetes, and depression. The most used drug in HCCI's data in 2021 was atorvastatin (various brand names, including Lipitor), a statin (i.e., to treat high cholesterol) with over 1 million unique users in HCCI's data (Table 1). The top 20 drugs in terms of use (days supplied) in HCCI's ESI data accounted for 40% of all use of prescription drugs.

The drug associated with the highest spending in HCCI's 2021 data was adalimumab (Humira), an anti-inflammatory drug used to treat rheumatoid arthritis (Table 2). Adalimumab carried a price tag of over $7,000 for a 30-day supply in the HCCI data and was associated with close to $19 billion in spending when weighted to be representative of spending in the full ESI population in 2021. Spending on adalimumab was 2.3 times higher than spending on the next-highest spending drug in the HCCI data, ustekinumab (Stelara), used to treat autoimmune conditions such as Crohn's Disease. The drug with the third highest spending was semaglutide (Ozempic, Wegovy, Rybelsus), an anti-diabetes drug which has been the subject of recent attention due to rising use to treat obesity. Spending on the top 20 prescription drugs in ESI accounted for 39% of spending on all drugs. 

Note that spending on prescription drugs reflects negotiated discounts from wholesale or list prices but does not account for manufacturer rebates provided through separate transactions. Increasing policy attention on prescription drugs, as well as changing market conditions (e.g., due to entry of new biosimilar options for Humira and other drugs), call for close monitoring of prescription drug prices and price changes. We hope that data on prescription drug use and spending shown here and additional downloadable data available with this brief will be useful for these efforts.

Table 1. Top 20 Drugs in Terms of Total Use in ESI in 2021*

Generic Name Average Price per 30-day supply, 2019 Average Price per 30-day supply, 2021 Total Number of Users, 2021Total Weighted Spending (in millions), 2021
atorvastatin $7.77 $5.86 1,117,733$409
*Ranked by total 2021 days supplied, weighted to be representative of the ESI population nationally; these data are available in downloadable data.

Table 2. Top 20 Drugs in Terms of Total Spending in ESI in 2021*

Generic Name Average Price per 30-day supply, 2019 Average Price per 30-day supply, 2021 Total Number of Users, 2021Total Weighted Spending (in millions), 2021
adalimumab   $6,426 $7,036 49,110$18,907
ustekinumab             $10,692$12,48513,223$8,145
semaglutide  $771$828150,472$5,650
dulaglutide $770$831106,086$5,061
dupilumab $3,380$3,28221,664$3,697
insulin aspart, human   $666$610112,943$3,490
empagliflozin $471$503114,338$3,373
emtricitabine; tenofovir alafenamide;bictegravir $2,965$3,18516,739$3,190
lisdexamfetamine $300$324212,884$2,892
risankizumab   $10,347$8,1907,643$2,648
ivacaftor;tezacaftor; ivacaftor;elexacaftor$25,217$24,3851,750$2,536
insulin glargine $392$370136,136$2,509
guselkumab              $7,065$7,4366,575$2,183
apixaban $428$46597,366$2,064
emtricitabine; tenofovir alafenamide$1,689$1,80524,020$2,054
*Ranked by total weighted spending. 


We restricted our analysis to adjudicated prescription claims with prescription coverage employer-sponsored insurer health plans and allowed amounts greater than $1 in 2019 and 2021. We weighted spending and utilization using ESI weights to develop estimates representative of the national ESI population younger than 65. ESI weights were calculated using the American Community Survey (ACS) 2021 5-year estimates Public Use Microdata Sample (PUMS). We grouped NDCs into corresponding generic product classes using NDC crosswalk from RxNorm.

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