COMPARISON OF BENEFIT DESIGN FOR DIABETES MEDICATIONS BETWEEN CONVENTIONAL MEDICARE ADVANTAGE PLANS AND CHRONIC CONDITION SPECIAL NEEDS PLANS
Author(s)
Jeah Jung, PhD1, Ge Song, MS2;
1George Mason University, Professor, Fairfax, VA, USA, 2George Mason University, Fairfax, VA, USA
1George Mason University, Professor, Fairfax, VA, USA, 2George Mason University, Fairfax, VA, USA
OBJECTIVES: Chronic Condition Special Needs Plans (C-SNPs) are a special type of Medicare Advantage (MA) plans than enroll only beneficiaries with a specific chronic condition(s). C-SNPs are the fastest growing MA plan type, with a 300% increase in their enrollment between 2017 and 2025. The most commonly targeted condition by C-SNPs is diabetes—over 90% of C-SNP enrollees are in plans specialized in diabetes. Exclusive enrollment of patients with the same condition may allow C-SNPs to provide benefits tailored to their specialized condition(s). We examined whether C-SNPs design prescription drug benefits differently from conventional MA plans (non-SNPs).
METHODS: We used 2022 Part D drug event data from a random 20% of MA enrollees and Part D drug formulary files. We compared three aspects of prescription drug benefits between C-SNPs and conventional MA plans: 1) Patient cost-sharing for diabetes drugs; 2) the number of diabetes drugs covered by the plan; and 3) the number of diabetes drugs requiring prior authorization. We used logistic regression to estimate adjusted differences in the likelihood of using any diabetes medication and patients’ out-of-pocket spending on diabetes medication.
RESULTS: C-SNP enrollees had lower monthly OOP spending on diabetes mediations, on average, than enrollees in conventional MA plans ($32 vs. $39). The number of diabetes medications included in drug formulary was smaller in C-SNPs than in non-SNPs (187 versus 241). However, C-SNPs were much less likely to require prior authorization for patients to receive diabetes medications than non-SNPs (17.11% vs. 52.3%).
CONCLUSIONS:
C-SNPs generally had more generous benefits for diabetes medications than conventional MA plans, suggesting that they may develop specialized care management strategies relevant to their target condition. Future research is needed to examine whether C-SNPs improve quality of care and health outcomes for patients with chronic conditions, compared with regular MA plans.
METHODS: We used 2022 Part D drug event data from a random 20% of MA enrollees and Part D drug formulary files. We compared three aspects of prescription drug benefits between C-SNPs and conventional MA plans: 1) Patient cost-sharing for diabetes drugs; 2) the number of diabetes drugs covered by the plan; and 3) the number of diabetes drugs requiring prior authorization. We used logistic regression to estimate adjusted differences in the likelihood of using any diabetes medication and patients’ out-of-pocket spending on diabetes medication.
RESULTS: C-SNP enrollees had lower monthly OOP spending on diabetes mediations, on average, than enrollees in conventional MA plans ($32 vs. $39). The number of diabetes medications included in drug formulary was smaller in C-SNPs than in non-SNPs (187 versus 241). However, C-SNPs were much less likely to require prior authorization for patients to receive diabetes medications than non-SNPs (17.11% vs. 52.3%).
CONCLUSIONS:
C-SNPs generally had more generous benefits for diabetes medications than conventional MA plans, suggesting that they may develop specialized care management strategies relevant to their target condition. Future research is needed to examine whether C-SNPs improve quality of care and health outcomes for patients with chronic conditions, compared with regular MA plans.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR73
Topic
Health Policy & Regulatory
Topic Subcategory
Insurance Systems & National Health Care
Disease
No Additional Disease & Conditions/Specialized Treatment Areas, SDC: Diabetes/Endocrine/Metabolic Disorders (including obesity)