With chronic conditions growing in prevalence among plan members, plan sponsors have their work cut out for them in designing benefits plans that provide adequate health support and employee satisfaction while also being cost effective, said Marie-Hélène Dugal, manager of pharmacy benefit strategy for Medavie Blue Cross, during Benefits Canada’s 2023 Face to Face Drug Plan Management Forum in December.

Between 2019 and 2022, Medavie saw a 23.3 per cent increase in per capita claims spend among its block of business for chronic disease. According to the 2023 Benefits Canada Healthcare Survey, 54 per cent of Canadian plan members live with at least one diagnosed chronic health condition, with mental-health conditions, arthritis and high cholesterol the three most common conditions.

Read: 54% of benefits plan members currently live with at least one chronic condition: survey

Medavie’s internal data found that biologics for autoimmune diseases was the top therapeutic category in 2022 (20.2 per cent of eligible claims), followed by diabetes (12.4 per cent), respiratory (5.7 per cent) and antidepressants (5.2 per cent). However, diabetes was the top trend driver in 2022, at a 2.1 per cent increase over 2021, due to a significant increase in Ozempic prescriptions, while biologics only increased by 0.9 per cent. Attention deficit hyperactivity disorder drugs, meanwhile, had the fastest growth in terms of number of claimants in 2022.

Dugal said plan members with diabetes don’t just tend to have a higher annual drug spend, they’re also more likely to have additional health conditions that require medication. Among plan members with diabetes, 66 per cent also used cardiac medication (compared to 26.7 per cent of plan members without diabetes), 64 per cent used cholesterol-lowering medication (versus 16.9 per cent without diabetes) and 35 per cent used gastrointestinal medication (compared to 22 per cent without diabetes).

While drug spend for chronic diseases make up a significant portion of plan sponsors’ benefit spend, managing cost constraints isn’t as simple as shifting money away from other elements of the plan, as benefits like massage or vision are highly appreciated and well-used by employees.

Read: 2022 Drug Plan Trends Report: High-cost drugs, DEI shaping drug plans

“If I’m an employer, I need to think of many different things when tying to find the right design for my benefits plan,” she said, noting employers have to balance benefits costs against the recruitment and retention boost of a good benefits plan as well as absence management and productivity concerns. 

A more holistic, prevention-forward approach is necessary to managing chronic diseases within the plan. This can include coverage for connected devices like blood glucose meters, educational materials for plan members and access to health-care professionals like health coaches through virtual care platforms and chronic disease management programs at pharmacies.

When looking at their drug plans, it’s important for plan sponsors to consider a cost-sharing component, managed formulary, generic substitution and biosimilar policies, prior authorization and leveraging a preferred pharmacy network to reduce dispensing fees.

Read: Gene, cell therapies raising questions of drug cost responsibilities: expert

There are also additional plan management features that employers can consider, which she said could lead to some of the most impactful changes. A step therapy program requires first-line treatments to try and fail, be upgraded or have additional therapies added before moving on to a more expensive therapeutic approach. Keeping a single level of copay for the plan can make a step therapy program “quite easy” to implement, she said, and technology can help to automate those reviews.

Using the same principle, a tiered formulary can ensure plan members start on a less costly drug first and, if it doesn’t work, they can upgrade to a more expensive one. A maximum allowable cost approach groups together drugs that treat the same conditions but are at different price points, “and then you can have access to more therapies on your formulary while limiting your cost to a reference price you have selected,” she said.

Read more coverage of the 2023 Face to Face Drug Plan Management Forum.