This is the first of three posts on this subject
Diabetes is one of the most common diseases in the United States as well as a leading cause of death. It affects nearly 10% of Americans, and its prevalence has been steadily increasing over the past several decades. Treatment for diabetes is complicated, often requiring several medications. In this Diabetes Awareness month series, we will explore characteristics of how the medications used to treat it are covered by ACA health insurance plans.
Vericred’s data science team investigated how 53 diabetes medications broken into 17 different classes based on their mechanisms of action are covered by small group and individual health plans. The results show that insulin along with biguanides (e.g., metformin) and sulfonylureas (e.g., glipizide), two of the oldest drug classes used to treat diabetes, have at least one member drug covered by every small group and individual plan. The remaining 14 of 17 drug classes are excluded entirely by at least some plans.* About two thirds of small group and individual plans have at least one class for which they do not cover any drugs. Individual plans are more likely than small group plans to exclude medication classes; 45% of individual plans exclude three or more classes compared to 9% of small group plans.
Consumers with diabetes, and employers shopping for insurance plans, should consider their plan options carefully, as coverage options for diabetes drugs are can vary widely across plans. This is particularly important for those with diabetes already on medication—if a new plan does not cover any drug in the same class as their current medication, their costs will rise greatly or their treatment regimen will need to change.
*Not covered for this analysis includes cases where a drug is not listed on the formulary, but members can make an application for an exception