This analysis of the top 200 drugs by prescriptions dispensed and total sales reveals key trends in today's pharmaceutical market.
Significant changes in health care utilization contributed to declining costs and slow spending growth of prescription drugs in the United States in 2012. Overall health care spending outpaced prescription drug spending and is likely to continue to do so for the next several years. The impact of recent changes has resulted in a dichotomy between the reduction of overall drug costs and increasing patient costs for specialty drugs.

Top Performers

The top 5 drug classes in terms of spending were oncologics ($25.9 billion), mental health ($23.5 billion), respiratory agents ($22.1 billion), antidiabetics ($22 billion), and pain ($18.2 billion). Patent expiries among oncologic agents resulted in a $744 million drop in spending, while spending on targeted agents grew by $2.5 billion. Spending on mental health agents declined by $6.2 billion, as top agents Zyprexa (olanzapine), Seroquel (quetiapine), Geodon (ziprasidone HCl), and Lexapro (escitalopram) lost patent protection. Antihypertensives were highest in prescription volume, followed by pain and mental health medications, antibacterials, and lipid regulators.

The top-earning single agent based on non-discounted spending was Nexium (esomeprazole) ($6 billion), followed by Abilify (aripiprazole) ($5.9 billion), Crestor (rosuvastatin calcium) ($5.1 billion), Advair Diskus (fluticasone propionate and salmeterol) ($4.9 billion), and Cymbalta (duloxetine delayed-release capsules) ($4.7 billion). Lipitor (atorvastatin calcium) was the top-earning agent of 2011, accounting for $20.1 bil-lion in total sales, but it lost its patent in November 2011. Subsequently, Lipitor was not among the top 20 earning agents in 2012. The newly available generic alternative to Lipitor, atorvastatin, was ranked number 21 last year, but earned almost $17 billion less than the brand product did in 2011.

Health Care Utilization

In 2012, the overall decline of per capita utilization of prescription medications and health care services highlights notable trends in health care spending. The total number of outpatient office visits, which are the lowest-cost medical interventions, declined for a third straight year, although the 0.9% decrease seen in 2012 was a significantly smaller drop than seen in 2010 or 2011. Nonemergency hospitalizations, outpatient treatment, and per capita medication use also declined, while emergency department admissions increased sharply.

Another important trend is the allocation of health care spending. Among privately insured health plan members, over 51% of total health care spending was concentrated among the top 5% most expensive members. Conversely, the bottom 50% of health plan members accounted for only about 3% of total spending. The latter group had a higher concentration of its costs attributed to pharmacy benefits, and thus this group was positively impacted by the increasing number of generic alternatives that have come to market following the large number of patent expiries in recent years.

For members with chronic or oncologic conditions, approximately 52% of total spending was attributed to outpatient medical costs while pharmacy costs for each group were 24.8% and 15.4%, respectively. For members with autoimmune or other specialty conditions, outpatient medical accounted for 32.4% of spending, and pharmacy spending was 45.2% of total spending.

Medication Spending and Growth

Nominal drug spending in 2012 totaled $325.8 billion, representing a 1% drop from the prior year. There was a nominal increase in prescription volume of 1.2% last year, but that equates to a 0.1% decline when adjusted on a per capita basis. Still, this is an improvement over the previous year, which showed a 1.1% decline in per capita utilization.

Areas of the largest volume gains in medication utilization included mental health, nervous system disorders, pain, and respiratory agents. The largest declines were seen in allergy therapies, antibacterials, and osteoporosis agents. Adults older than 50 years consumed the largest amount of medication last year, accounting for 64% of prescriptions dispensed. Adults aged 26 to 49 years and individuals 18 years and younger accounted for the largest decline in medication utilization. Prescription utilization among individuals aged 19 to 25 years also declined in 2012, in contrast to the increased utilization seen in 2011 when the provision of the Affordable Care Act allowing them to remain on their parents’ health insurance took effect. It remains to be seen whether the decrease in prescription drug utilization will positively or negatively impact overall health care costs in the future.

Spending on brand-name medications dropped by $11.4 billion, reaching a total of $230.2 billion. The decrease in the volume of brand name prescriptions accounted for a $3.9 billion reduction in spending, while the loss of patent exclusivity of some products resulted in a $28.9 billion decline. Spending for new brands grew by $5.6 billion, and price increases on existing brand products raised spending another $15.7 billion.

Generics represent 84% of total prescriptions dispensed in 2012 and 28% of total spending. Currently in the retail setting, when a generic option is available, it is dispensed in place of brand products 95% of the time. Over the past decade, generic prescription volume has risen by 30%, although this growth is not expected to exceed 87% of total prescriptions dispensed through 2017 due to fewer upcoming patent expiries compared with previous years.

Patient Costs

Changes in health insurance plans have caused significant shifts in patient costs for prescription medications. Traditional health care plans, such as PPOs and HMOs, are now carrying significantly higher deductibles. Consumer-driven health plans, which combine high deductibles with coinsurance costs of 20% or more after deductibles, have become more popular and currently represent 19% of insured patients. Patient costs correlate directly with treatment adherence and compliance, which can dramatically impact overall clinical outcomes.

While out-of-pocket health care costs are rising overall, prescription drug costs are decreasing for most patients as a result of the increased utilization of generics. Health care deductibles increased by 48% in 2012, averaging $818 per patient. Pharmacy copays and coinsurance actually decreased, dropping from $123 per patient in 2011 to $121 in 2012. Nearly 72% of all prescriptions dispensed in the retail setting had an average copay of $10 or less. Medicare Part D prescriptions cost less than $10 approximately 84% of the time, while 99% of Medicaid prescriptions cost less than $10. Drugs with the highest out-of-pocket costs were biologics and specialty drugs, which account for 3% of the total retail prescriptions dispensed in 2012.

Trends to Watch

In 2012, 28 new molecular entities (NMEs) were launched, which continues the trend seen over the past several years. Several agents with new mechanisms of action in their respective therapy classes became available, including treatments for chronic kidney disease, multiple sclerosis, and HIV. Additionally, 7 orphan disease medications were launched, offering new therapy options for rare diseases affecting fewer than 200,000 patients, such as cystic fibrosis, chronic myeloid leukemia, and Gaucher disease. Nine oncology NMEs were released last year, which was the highest number in the past decade.

It is likely that growing availability of new agents and treatment options for a number of diseases will continue into the next few years. The 2012 FDA Safety and Innovation Act included a provision for the designation of Breakthrough Therapies, which can lessen the burden of the development and review processes for some new medications aimed at treating serious diseases. Additionally, there are several highly anticipated agents on the horizon that have been approved or that are expected to gain FDA approval in 2013. Kadcyla (ado-trastuzumab emtansine) was approved in February 2013 and has been called the “smart bomb” for breast cancer. Invokana (canagliflozin) is the first agent approved in a new class of agents targeting type 2 diabetes. Tecfidera (dimethyl fumarate) is a newly approved oral agent targeting multiple sclerosis. Several new oral hepatitis C regimens are expected to be approved in late 2013 and in 2014.

The decline in prescription drug sales may be the product of drug therapy optimization and streamlining, which would ultimately lead to improved outcomes. Alternatively, this decline may also reflect a tendency for some patients to defer health care costs and preventive treatments, leading to more advanced complications and ultimately higher health care costs. Changes in health care coverage may benefit the majority of patients using low-cost generics for the most commonly treated disease states, but there will likely continue to be a small segment of patients facing large out-of-pocket expenses for specialty medications treating specific conditions.

Top 200 Products of 2012 by Total Dollars
Rank Product Manufacturer Sales ($) Rank Product Manufacturer Sales ($)
1 Nexium AstraZeneca $5,989,000,000 11 Singulair Merck & Company $3,300,000,000
2 Abilify Otsuka America $5,870,000,000 12 Rituxan Genentech $3,197,000,000
3 Crestor AstraZeneca $5,092,000,000 13 Plavix Bristol-Myers Squibb/sanofi-aventis $2,971,000,000
4 Advair Diskus GlaxoSmithKline $4,889,000,000 14 Atripla Bristol-Myers Squibb Gilead $2,899,000,000
5 Cymbalta Lilly $4,720,000,000 15 Spiriva Handihaler Boehringer Ingelheim $2,833,000,000
6 Humira Abbvie $4,609,000,000 16 Oxycontin Purdue Pharma $2,808,000,000
7 Enbrel Amgen $4,337,000,000 17 Januvia Merck & Company $2,670,000,000
8 Remicade Centocor $3,876,000,000 18 Avastin Genentech $2,661,000,000
9 Copaxone Teva CNS $3,581,000,000 19 Lantus sanofi-aventis $2,327,000,000
10 Neulasta Amgen $3,460,000,000 20 Truvada Gilead Sciences $2,305,000,000
Rank Product Manufacturer Rank Product Manufacturer Rank Product Manufacturer
21 Lantus Solostar sanofi-aventis 81 Lexapro Forest 141 Risperdal Consta Janssen
22 Epogen Amgen 82 Synagis Medimmune 142 Premarin Pfizer
23 Diovan Novartis Rx 83 Benicar Daiichi Sankyo 143 Zytiga Centocor
24 Lyrica Pfizer 84 Lunesta Sunovion 144 Welchol Daiichi Sankyo
25 Lipitor Pfizer 85 Evista Lilly 145 Metoprolol Succinate Par Pharm
26 Celebrex Pfizer 86 Prevnar 13 Pfizer 146 Onglyza Bristol-Myers Squibb
27 Herceptin Genentech 87 Enoxaparin Sodium Sandoz 147 Xifaxan Salix
28 Gleevec Novartis Rx 88 Synthroid Abbvie 148 Byetta Amylin
29 Namenda Forest 89 Renvela Genzyme 149 Aggrenox Boehringer Ingelheim
30 Actos Takeda USA 90 Atorvastatin Calcium Actavis 150 Opana Er Endo Labs
31 Avonex Biogen 91 Xeloda Roche 151 Aloxi Eisai
32 Lucentis Genentech 92 Zyvox Pfizer 152 Privigen CSL Behring
33 Vyvanse Shire Us Inc 93 Ventolin HFA GlaxoSmithKline 153 Lumigan Allergan
34 Suboxone Reckitt Benckiser 94 Velcade Millennium 154 Intuniv Shire US
35 Seroquel AstraZeneca 95 Xolair Genentech 155 Travatan Z Novartis Vision
36 Zetia Merck/Schering-Plough 96 Sensipar Amgen 156 Pulmozyme Genentech
37 Methylphenidate ER Actavis 97 Erbitux Imclone Systems 157 Pneumovax 23 Merck & Company
38 Androgel Abbvie 98 Humalog Kwikpen Lilly 158 Zyprexa Lilly
39 Incivek Vertex 99 Stelara Centocor 159 HYCD/APAP Actavis
40 Diovan HCT Novartis Rx 100 Xgeva Amgen 160 Angiomax The Medicines Co
41 Lidoderm Endo Labs 101 Benicar HCT Daiichi Sankyo 161 Lialda Shire US
42 Atorvastatin Calcium Ranbaxy 102 Sandostatin LAR Novartis Rx 162 Cimzia UCB Pharma
43 Symbicort AstraZeneca 103 Mirena Bayer Healthcare 163 Geodon Pfizer
44 Rebif EMD Serono 104 Zostavax Merck & Company 164 Actonel Warner-Chilcott
45 Novolog Novo Nordisk 105 Focalin XR Novartis Rx 165 Prograf Astellas
46 Seroquel XR AstraZeneca 106 Tarceva Genentech 166 Fentanyl Mylan
47 Tricor Abbvie 107 Cubicin Cubist 167 Ortho-Tri-cyclen Lo 28 Ortho
48 Alimta Lilly 108 Detrol LA Pfizer 168 Novolog Flxpen Mix Novo Nordisk
49 Eloxatin sanofi-aventis 109 Zometa Novartis Rx 169 Ranexa Gilead Sciences
50 Levemir Novo Nordisk 110 Treanda Teva Oncology 170 Qvar Teva Respiratory
51 Combivent Boehringer Ingelheim 111 Colcrys Takeda USA 171 Afinitor Novartis Rx
52 Viagra Pfizer 112 Solodyn Medicis 172 Invega Janssen
53 Proair HFA Teva Respiratory 113 Escitalopram Oxalate Teva 173 Tysabri Elan
54 Procrit Ortho Biotech 114 Gardasil Merck & Company 174 Temodar Schering
55 Niaspan Abbvie 115 Pristiq Pfizer 175 Nuvigil Teva CNS
56 Nasonex Schering 116 Pegasys Convenience Pack Roche 176 Sprycel Bristol-Myers Squibb
57 Novolog Flexpen Novo Nordisk 117 Invega Sustenna Janssen Pharm 177 Tasigna Novartis Rx
58 Lovaza GlaxoSmithKline 118 Strattera Lilly 178 Adacel sanofi-aventis
59 Humalog Lilly 119 Trilipix Abbvie 179 Valcyte Roche
60 Flovent HFA GlaxoSmithKline 120 Revlimid Celgene 180 Exforge Novartis Rx
61 Neupogen Amgen 121 Asacol Warner-Chilcott 181 Nutropin AQ Genentech
62 Reyataz Bristol-Myers Squibb HIV 122 Bystolic Forest 182 Zosyn Pfizer
63 Vytorin Merck & Company 123 Viread Gilead Sciences 183 Amphetamine Salts Teva
64 Isentress Merck & Company 124 Enoxaparin Sodium Winthrop 184 Effient Lilly
65 Budesonide Teva 125 Loestrin 24 Fe Warner-Chilcott 185 Claravis Teva
66 Janumet Merck & Company 126 Yervoy Bristol-Myers Squibb 186 Advair HFA GlaxoSmithKline
67 Aranesp Amgen 127 Avodart GlaxoSmithKline 187 Chantix Pfizer
68 Cialis Lilly 128 Lexiscan Astellas 188 Reclast Novartis Rx
69 Aciphex Eisai 129 Lovenox sanofi-aventis 189 Vidaza Celgene
70 Adderall XR Shire US 130 Epzicom Viiv Healthcare 190 Abraxane Celgene
71 Restasis Allergan 131 Exelon Novartis Rx 191 Gammagard Liquid Baxter Hyland
72 Pradaxa Boehringer Ingelheim 132 Amphetamin Salt ER Global 192 Tamiflu Roche
73 Gilenya Novartis Rx 133 Gamunex-C Grifols USA 193 Complera Gilead Sciences
74 Prezista Ortho Biotech 134 Nuvaring Organon 194 Maxalt Merck & Company
75 Betaseron Bayer Healthcare 135 Amphetamin Salt Er Teva 195 Ciprodex Novartis Vision
76 Orencia Bristol-Myers Squibb 136 Escitalopram Oxal Mylan 196 Activase Genentech
77 Varivax Merck & Company 137 Provigil Teva CNS 197 Vimpat Schwarz
78 Vesicare Astellas 138 Norvir Abbvie 198 Simponi Centocor
79 Victoza 3-Pak Novo Nordisk 139 Epipen 2-Pak Mylan Specialty 199 Synvisc-One Genzyme Corp
80 Dexilant Takeda USA 140 Forteo Lilly 200 Sutent Pfizer
Market Limits: Prescription drugs only. Data provided by IMS Health, a health care information company.
Top 200 Products of 2012 by Total Prescriptions
Rank Product Manufacturer Total Rxs Rank Product Manufacturer Total Rxs
1 HYCD/APAP Actavis 56,118,000 11 Synthroid Abbvie 23,476,000
2 Levothyroxine Sodium Mylan 47,641,000 12 Nexium AstraZeneca 22,286,000
3 HYCD/APAP Mallinckrodt 44,967,000 13 Atorvastatin Ca Ranbaxy 22,229,000
4 Lisinopril Lupin 42,621,000 14 Ibuprofen (Rx) Amneal 21,560,000
5 HYCD/APAP Qualitest Products 27,983,000 15 Trazodone Hcl Teva 21,186,000
6 Simvastatin Lupin 27,955,000 16 Metoprolol Tartrate Mylan 20,646,000
7 Azithromycin Teva 26,188,000 17 Azithromycin Greenstone 20,149,000
8 Proair HFA Teva Respiratory 25,384,000 18 Warfarin Sodium Taro 19,173,000
9 Crestor AstraZeneca 25,325,000 19 Cymbalta Lilly 18,891,000
10 Levothyroxine Sodium Lannett 25,192,000 20 Fluticasone Propionate Roxane 18,502,000
Rank Product Manufacturer Rank Product Manufacturer Rank Product Manufacturer
21 Singulair Merck &
81 Citalopram HBR Torrent 141 Simvastatin Zydus
22 Hydrochloro-
82 Atenolol Mylan 142 Carvedilol Mylan
23 Ventolin HFA GlaxoSmith-
83 Tramadol HCl Zydus 143 Paroxetine HCl Zydus
24 Advair Diskus GlaxoSmith-
84 Nasonex Schering 144 Triamterene/
25 Pravastatin
Teva 85 Simvastatin Northstar Rx 145 Potassium Cl Sandoz
26 Amoxicillin Sandoz 86 Carvedilol Teva 146 Doxycycline Hyclate Actavis
27 Amlodipine Besy Greenstone
87 Cephalexin Teva 147 Bupropion
28 Omeprazole (Rx) Mylan 88 Tramadol HCl Teva 148 Doxycycline Hyclate West Ward
29 Omeprazole (Rx) Sandoz 89 Warfarin Sodium Teva 149 Lovastatin Lupin
30 Amoxicillin Teva 90 Venlafaxine HCl
Teva 150 APAP/CD Qualitest Products
31 Lisinopril/HCTZ Lupin 91 Cyclobenzaprin
Mylan 151 Ciprofloxacin
Dr. Reddy's
32 Metoprolol
Par Pharm 92 Abilify Otsuka America Ph 152 Klor-Con M20 Upsher-
33 Hydrochloro-
Teva 93 Lisinopril Wockhardt America 153 Lexapro Forest
34 Amlodipine
Camber 94 Furosemide Roxane 154 Tricor Abbvie Inc
35 Oxycodone/APAP Mallinckrodt 95 Zolpidem
Torrent 155 Temazepam Mylan
36 Sertraline HCl Camber 96 Januvia Merck & Company 156 Albuterol Mylan
37 Amlodipine
Lupin 97 Metformin HCl Aurobindo 157 Gabapentin Actavis
38 Diovan Novartis Rx 98 Lisinopril Teva 158 Cyclobenzaprin HCl Qualitest Products
39 Alprazolam Actavis 99 Lisinopril Sandoz 159 Famotidine Teva
40 Metformin HCl Zydus 100 Naproxen Amneal 160 Triamcinolone Acetonide Perrigo
41 Metformin HCl Teva 101 Methylphenidate
Actavis 161 Alprazolam Sandoz
42 Simvastatin Aurobindo 102 Cyclobenzaprin
Cadista 162 Alendronate Sodium Actavis
43 Fluconazole Teva 103 Diovan HCT Novartis Rx 163 Oxycodone HCl Mallinckrodt
44 Oxycodone/APAP Actavis 104 Prednisone Roxane 164 Amoxicillin Greenstone
45 Omeprazole (Rx) Dr. Reddy's 105 Viagra Pfizer 165 Triamterene/
46 Omeprazole (Rx) Kremers
106 Metoprolol Succinate Wockhardt America 166 Atorvastatin Calcium Mylan
47 SMX/TMP Amneal 107 Lantus Solostar sanofi-
167 Alprazolam Qualitest Products
48 Lorazepam Actavis 108 Potassium Cl Actavis 168 Clindamycin
49 Meloxicam Lupin 109 Zetia Merck/
169 Tamsulosin HCl Zydus
50 Prednisone West Ward 110 Furosemide Teva 170 Levothyroxine Sodium Sandoz
51 Clonazepam Teva 111 Suboxone Reckitt Benckiser 171 Atenolol Zydus
52 Tramadol HCl Amneal 112 Namenda Forest 172 Lisinopril Mylan
53 Furosemide Ranbaxy 113 Clonazepam Mylan 173 Ranitidine HCl Amneal
54 Sertraline HCl Greenstone
114 Zolpidem
Qualitest Products 174 Benicar Daiichi Sankyo Inc
55 Plavix Bristol-Myers
115 Lorazepam Ranbaxy 175 Symbicort AstraZeneca
56 Gabapentin Amneal 116 Amoxicillin West Ward 176 Mupirocin Teva
57 Fluoxetine HCl Teva 117 Cialis Lilly 177 Niaspan Abbvie Inc
58 Simvastatin Teva 118 Prednisone Actavis 178 Lovaza GlaxoSmith-
59 Vitamin D Teva 119 Amphetamine
Teva 179 Prednisone Qualitest Products
60 Lisinopril Actavis 120 Methylpred-nisolone Cadista 180 Premarin Pfizer
61 Atorvastatin
Actavis 121 Pantoprazole Sodium Teva 181 Nuvaring Organon
62 Fluticasone
122 Diazepam Mylan 182 Dexilant Takeda USA
63 Simvastatin Dr. Reddy's 123 Allopurinol Mylan 183 Metoprolol
64 Citalopram HBR Amneal 124 Furosemide Mylan 184 Cheratussin AC Qualitest Products
65 Lantus sanofi-aventis 125 Amoxicillin Trihydrate/ Clavulanate Potassium Dr. Reddy's 185 Hydrochloro-thiazide Heritage
66 Ibuprofen (Rx) Dr. Reddy's 126 Lorazepam Mylan 186 Metoprolol Tartrate Ranbaxy
67 Amoxicillin
Sandoz 127 Gabapentin Camber 187 Levoxyl Pfizer
68 Vyvanse Shire Us Inc 128 Escitalopram Oxalate Mylan 188 Penicillin VK Teva
69 Metoprolol
Actavis 129 Ranitidine HCl Teva 189 Metronidazole Teva
70 Ciprofloxacin HCl Actavis 130 Atenolol Ranbaxy 190 Amlodipine Besylate Ascend Labs
71 Lipitor Pfizer 131 Omeprazole
Apotex 191 HYCD/APAP Amneal
72 Escitalopram
Teva 132 Digoxin Lannett 192 Azithromycin Sandoz
73 Metformin HCl Mylan 133 Bystolic Forest 193 Naproxen Teva
74 Spiriva
134 Amitriptyline
Mylan 194 Allopurinol Qualitest Products
75 Alprazolam Dava 135 Flovent HFA GlaxoSmith-
195 Actos Takeda USA
76 Celebrex Pfizer 136 Pravastatin
Glenmark 196 Diazepam Teva
77 Zolpidem Tartrate Teva 137 Loestrin 24 Fe Warner-
197 Bupropion
78 Alprazolam Greenstone
138 Risperidone Mylan 198 Losartan Potassium Pack
79 Sertraline HCl Lupin 139 Oxycontin Purdue 199 Lidoderm Endo Labs
80 Lyrica Pfizer 140 Simvastatin Accord Healthcare 200 Gabapentin Glenmark
Market Limits: Prescription drugs only. Data provided by IMS Health, a health care information company.

Dr. Bartholow is a clinical pharmacist in the VA Southern Nevada Healthcare System in Las Vegas, Nevada.

  1. Declining medicine use and costs: for better or worse? a review of the use of medicines in the United States in 2012. IMS Institute for Healthcare Informatics. Accessed May 2013.