Diabetes is a rapidly growing and complex medical condition that accounts for 11% of all health spending.
In 2022, 7.4% of our block of business was claiming diabetes drugs, up from 6.6% in 2021, with an average annual drug cost per each claimant of $1,534.
This has made chronic disease management a key focus in the national access-to-care discussion, recognizing the burden of diabetes and obesity on the health care system. There’s also a greater understanding of the strong correlations between diabetes, obesity and disability – and it goes in both directions – with studies showing that diabetes and obesity can be both a predictor and a consequence of disability.
Studies have consistently found persons with diabetes to have a 50%–90% increased risk of disability, and excess weight is one of the strongest predictors of diabetes.
Ozempic driving increase
Diabetes is the number two overall therapeutic drug category representing 12.4% of total eligible spend, second to only biologics for autoimmune diseases at 20.2%, our claims data shows. For the second consecutive year, one drug — Ozempic — is driving the increased trend for diabetes drugs.
Because Ozempic is being claimed so much more than in the past, it’s increasing the average cost per claimant for diabetes treatment and the number of claimants. Ozempic accounted for 35.8% of the total 2022 eligible spend for diabetes on our block of business, or 19.5% of contribution to trend, compared to 22.5% (11.2% of trend) in 2021.
It’s not only how well drugs like Ozempic and Jardiance help control diabetes that have contributed to their popularity, but their effects on weight loss (Ozempic) and cardiovascular health (Jardiance) that have made them treatments of choice.
Upwards of 50% of our block of groups now provide access to weight loss module medications for their members.
Diabetes is an important and expensive therapeutic category to manage, impacts other therapeutic categories and overlaps with obesity management. This is why data, analytics, pricing, and population are essential elements of our standard benefit management strategy.
Diabetes management solutions
Medavie Blue Cross offers a range of solutions and tools for managing chronic conditions like diabetes and obesity. Today, we take three different approaches to drug coverage for Ozempic and other GLP-1 drugs with a new standard on the way. All coverage includes dosage limits to that of the most cost-effective for diabetes. The current standard is to cover the drug’s regular benefit, with options under tiered copay plans, such as RxChoices and Step Therapy plans so that first-line treatments for diabetes have preferential coverage, and Ozempic and similar drugs are second-line. Typically, patients looking solely for the weight loss effect require a higher dosage than what we cover.
Enhancing drug management
The evolution of our standard option that is coming soon in Q3 2023 will be leveraging the technology we have developed as the owner and operator of our own pharmacy benefit management system, that offers real-time assessment to further enhance drug management. This will likely mean that, for most plans, Ozempic will not be covered for members without a diabetes diagnosis.
Weight loss drugs are now standard coverage through our flagship formulary, Rxperience, but they require Prior Authorization to validate they are indeed used for patients with obesity. We also have clients who prefer to not have Prior Authorization apply, but manage this category with a plan maximum, for example, of $3,200 a year.
Drug coverage, however, is only one way we help treat chronic conditions. That’s because at Medavie Blue Cross, we believe a holistic approach to chronic disease management is likely to produce more long-term success ― and we are backed by medical evidence.
Studies show that those who receive coaching and education services as part of a holistic approach to treatment are more successful in delaying, managing, and even reversing their condition than those who don’t.
We go beyond treating the condition and targeting the contributing factors that lead to chronic health issues. Our programs integrate health coaching with healthy, active living education so that members gain the knowledge and confidence they need to self-manage their condition
Expanded diabetes care program
An example is our diabetes care program, which was enhanced in early April and is now called the 360 Total Care program. This holistic health coaching program has been expanded. It now focuses on helping members with diabetes, high blood pressure/cholesterol or obesity, providing education and support to members in their journey toward overall wellness. This expanded program is also eligible for reimbursement, using direct billing to Medavie, under our industry-first Managing Chronic Disease program.
To learn more about our drug plan management solutions
and chronic disease management programs, speak to your Medavie Blue Cross account representative.
To hear the full Insights webinar discussion on obesity and diabetes, listen to this recording.