Title
APPROVAL OF THE AMENDMENT TO THE EXPRESS SCRIPTS CONTRACT FOR ADDITION OF THE ENCIRCLE Rx PROGRAM EFFECTIVE 02/01/2025
Description
Glucagon-like peptide, or GLP-1 agonists are a class of medications that mainly help manage blood sugar (glucose) levels in people with diabetes. Some GLP-1 agonists can also help treat obesity. With the recent FDA approval for these drugs for weight loss, there has been a surge in requests from patients, prescriptions from doctors and associated costs.
From 2022 to 2023, The Sarasota County School Board pharmacy plan with Express Scripts saw an increase of about 96% for GLP-1’s or $2,857,499. (Examples of some increases are as follows: Ozempic saw a 33.7% increase; Munjaro increased 1,155%; Wegovy increased 322%) For 2024, the utilization is expected to continue to increase due to advertising from pharmaceutical companies and member demand.
Currently, there are very few guardrails in place to ensure only those who really need these prescriptions are authorized to receive them. By adding the Encircle Rx program, the pharmacy plan will be able to tighten the approval process and manage GLP-1 utilization by combining prior authorization with coaching and lifestyle management support. With the Encircle Rx program, those with diabetes will have to have a prior authorization with previous claims to substantiate diabetes diagnosis. If no data exists, provider will have to provide proof as outlined in the program.
For the Encircle Rx weight loss program, members must satisfy a prior authorization criterion of a BMI greater than or equal to 32 or 27 if they also have two documented comorbidities such as hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, and/or cardiovascular disease. Members will also need to participate in the Omada Weight Management Care Value Program. This requires weigh-in 4x/month and engage with the app 4x/month. The prior authorization will only be good for 5 months and members must have lost 5% to be approved again.
Gap Analysis
Currently there are no programs in place other than a prior authorization.
Previous Outcomes
N/A
Expected Outcomes
Utilization and costs will have better controls with only eligible members obtaining prescriptions. The program does provide for a 3:1 savings guarantee.
Strategic Plan Goal
Pillar 3 - Every Employee Valued
Priority 1 - Recruit, Recognize, and Retain
Priority 2 - Foster Employee Engagement
Pillar 4 - Every School Equipped
Priority 1 - Maintain Sustainable Financial Practices
Recommendation
That the amendment to the Express Scripts contract for addition of the Encircle Rx Program be approved as presented.
Contact Information
LYNN PETERSON lynn.peterson@sarasotacountyschools.net
ASHLEY ROMADKA ashley.romadka@sarasotacountyschools.net
Financial Impact
Encircle Rx Diabetes Program: $0.25 Per Member Per Month
Encircle Rx Weight Loss Program: $1.25 Per Member Per Month.
Estimated Financial impact - $3,537
Source: Internal Service Fund