Three main drug categories — diabetes, asthma and stimulants for attention deficit hyperactivity disorder — accounted for rising drug claims in 2022, according to Lavina Viegas, Telus Health’s director of client account management, speaking during Benefits Canada‘s 2023 Benefits & Pension Summit in June.
Referring to Telus Health’s 2023 drug plan trends report, she said the diabetes category saw an overall cost increase of $745.2 million, representing nearly 17 per cent growth and helping to vault this category into the No. 1 spot. In particular, a strong increase in claims for the diabetes drug Ozempic was a main contributor to why diabetes was the most expensive category in 2022.
While Ozempic and other diabetes medications — classified as GLP-1 class drugs — are indicated for diabetes, the added benefit is they can be used for weight loss, said Viegas, noting a portion of claimants were solely using GLP-1 drugs with no other first-line diabetic medications in their claims history. “From this, we can hypothesize that some claimants are using these drugs off label for weight loss.”
With that in mind, she suggested some options for drug plan sponsors to mitigate potential risk, including: step therapy, which looks at whether a plan member has had previous diabetes treatment before allowing coverage for GLP-1 drugs; prior-authorization, which can ensure a plan member has actually been diagnosed with diabetes; and generic substitution programs, which can be critical in passing along the cost savings of generic drugs.
Returning the the drug trends report, Viegas noted asthma ranked No. 4 among the top 10 most expensive health conditions in Canada, accounting for $306.4 million of total eligible costs in 2022 — and up 17 per cent from the previous year. However, the overall costs for asthma were down in 2021 by almost nine per cent, she added, noting one explanation for this could be the restrictions put in place by the coronavirus pandemic, when people had lower exposure to airborne illnesses and so were less likely to be dependent on inhalers.
She also highlighted a third drug category — stimulants for ADHD — which represented $294.6 million in eligible costs, up 22 per cent since 2021. In 2022, people between the ages of 30 and 39 showed the strongest growth in claimants, compared to 2019 and 2020 when that age group didn’t really show up. “There’s a strong growth now in an older population for a class of drugs that are typically associated with the under 19 population.”
Plan sponsors have several tools that can be used for drug plan management, said Viegas. For example, leveraging private product listing agreements can provide plan member choice and maintain plan sustainability. Another suggestion was a biosimilar switching policy, where the biologic is only reimbursed to the cost of the biosimilar drug.
She also highlighted prior-authorization again, noting it’s a way to ensure lower-cost alternatives, like biosimilars, are used first — a plan member must demonstrate trial and failure before they gain access to a biologic. And she suggested plan sponsors consider using a managed formulary.
“This would help ensure there’s more of a pharmacoeconomic evaluation of new products coming to the market and that only cost-effective products are added to the plan. The key is to stay informed as the landscape is evolving constantly and quickly.”
Read more coverage of the 2023 Benefits & Pension Summit.