MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT th Edition. With a Focus on How Co-Occurring Conditions Impact Diabetes Care

Transcription

1 MANAGED CARE SINCE FLHCC FLORIDA TYPE 2 DIABETES REPORT th Edition With a Focus on How Co-Occurring Conditions Impact Diabetes Care 1987 DIGEST SERIES

2 FLHCC FLORIDA TYPE 2 DIABETES REPORT INTRODUCTION Sanofi U.S. (Sanofi), in conjunction with the Florida Health Care Coalition (FLHCC), is pleased to present the sixth edition of the FLHCC Florida Type 2 Diabetes Report for This report provides an overview of pertinent demographic, utilization, charge, and pharmacotherapy measures for Type 2 diabetes patients in key local markets in Florida, with a focus on how co-occurring conditions can impact diabetes care. The report also provides state and national benchmarks, which help providers and employers better identify opportunities to serve the needs of their patients. All data are drawn from the Sanofi Managed Care Digest Series. The data in this report (current as of calendar year 2017) were gathered by IQVIA, Durham, N.C., a leading provider of innovative health care data products and analytic services. A review process takes place, before and during production of this report, between IQVIA and Forte Information Resources, LLC. Sanofi, as sponsor of this report, maintains an arm s-length relationship with the organizations that prepare the report and carry out the research for its contents. The desire of Sanofi is that the information in this report be completely independent and objective. CONTENTS Executive Summary... 3 Patient Demographics... 4 Laboratory... 5 Charges... 6 Pharmacotherapy... 7 Type 2 Diabetes Patients With: CV Obesity Methodology/ADA Guidelines CONTACTS Karen van Caulil, Ph.D. President and CEO Florida Health Care Coalition (FLHCC) P E. info@flhcc.org Gary Behrens National Account Director Sanofi P E. Gary.Behrens@sanofi.com Caroline Noke Regional Account Executive Sanofi P E. Caroline.Noke@sanofi.com SINCE 1987 MANAGED CARE DIGEST SERIES Provided by: Sanofi U.S., Bridgewater, NJ Developed and produced by: 2018 Forte Information Resources LLC Denver, CO Data provided by: IQVIA, Durham, NC 2 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

3 FLHCC FLORIDA TYPE 2 DIABETES REPORT EXECUTIVE SUMMARY The FLHCC Florida Type 2 Diabetes Report offers a broad overview of the state of diabetes with a focus on how co-occurring diagnoses such as depression, cardiovascular disease, obesity, and neuropathy impact care in markets across Florida. The Report provides state and national benchmarks for commercially insured patients (often in comparison with their peers with Medicaid or Medicare coverage) to identify potential gaps in care and reinforce positive trends. Current as of 2017 and spanning several years, the data in this Report encompass more than 11.7 million unique patients nationally with Type 2 diabetes of these, more than 1 million resided in Florida. This year s Report provides several observations to help providers and employers better meet the needs of employees. For example: The percentage of Florida adults self-reporting who have been told by a physician that they had diabetes or prediabetes increased from 2011 to 2016; the rate of diabetes among the Florida population eclipsed that of the nation in all six years shown. Roughly one in every eight Type 2 diabetes patients with commercial insurance had an A1c level greater than 9.0% in 2017, a percentage that exceeded the corresponding benchmark for Medicare by nearly two percentage points. In every profiled market, the percentage of commercial Type 2 diabetes patients with a comorbidity of depression increased from 2015 to 2017; furthermore, in all three years shown, these shares surpassed those of the nation. In 2017, professional charges for commercially insured Florida Type 2 diabetes patients who had depression, cardiovascular disease, obesity, or neuropathy were higher than the respective overall averages for the state, regardless of setting. PERCENTAGE OF ADULTS SELF-REPORTING DIABETES AND PREDIABETES DIAGNOSIS, FLORIDA, Florida: Nation: Diabetes Diabetes Prediabetes Prediabetes 12% Percentage of Population 9% 2% 1% Data source: Centers for Control and Prevention Behavioral Risk Factor Surveillance System 2018 NOTE: On pages 3 4, Behavioral Risk Factor Surveillance System (BRFSS) data on diabetes and prediabetes are based on responses to the survey question, Have you ever been told by a doctor that you have diabetes? MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

4 PATIENT DEMOGRAPHICS RATES OF DEPRESSION, CV DISEASE, OBESITY, NEUROPATHY ARE HIGH IN FL In 2017, Florida Type 2 diabetes patients with commercial insurance were more apt than their counterparts nationally to have any of the four profiled co-occurring conditions: depression, cardiovascular (CV) disease, obesity, or neuropathy. Meanwhile, commercially insured Type 2 diabetes patients statewide were less likely than their peers with Medicare coverage to have an A1c level at or below 7.0%. PERCENTAGE OF FLORIDA POPULATION SELF-REPORTING DIABETES, BY GENDER, Percentage of Population Male Female 13% 12% 11% 10% 9% Data source: Centers for Control and Prevention Behavioral Risk Factor Surveillance System 2018 PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY PAYER, Commercial Insurance 1 Medicaid Medicare Lakeland 50.0% 43.3% 10.7% 14.1% 38.5% 41.6% Miami Orlando Palm Bay Tampa Florida NATION 49.1% 48.0% 14.2% 15.4% 35.7% 35.5% DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS, BY AGE, Lakeland 0.1% n/a 1.4% 1.9% 40.9% 43.4% 43.2% 41.9% 14.5% 12.8% Miami % Orlando Palm Bay Tampa Florida NATION 0.4% 0.4% 2.6% 2.7% 46.7% 48.7% 38.0% 36.8% 12.4% 11.4% 1 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. NOTE: Throughout this report, the percentages shown are representative of the universe of Type 2 diabetes patients for whom claims data have been collected in a given year. The Lakeland market includes Winter Haven; the Miami market includes Fort Lauderdale and West Palm Beach; the Orlando market includes Kissimmee and Sanford; the Palm Bay market includes Melbourne and Titusville; the Tampa market includes St. Petersburg and Clearwater. An n/a indicates that data were not available. 4 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

5 LABORATORY PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE AND PAYER, % % % >9.0% Comm. Ins. 2 Medicaid Medicare Comm. Ins. 2 Medicaid Medicare Comm. Ins. 2 Medicaid Medicare Comm. Ins. 2 Medicaid Medicare Lakeland 55.6% 45.5% 58.2% 17.8% 16.2% 18.3% 12.6% 15.0% 11.7% 14.1% 23.2% 11.8% Miami Orlando Palm Bay Tampa Florida NATION 53.4% 48.3% 57.8% 19.6% 17.2% 19.4% 12.5% 12.9% 11.6% 14.5% 21.6% 11.3% DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING ANY INSULIN PRODUCTS, BY A1c LEVEL RANGE, ,3 36% 7.0% % % >9.0% 27% 18% 9% 32.2% 26.4% 21.8% 19.6% 25.5% 22.9% 22.1% 29.6% 23.3% 20.8% 32.6% 29.8% 28.6% 25.6% 16.1% 28.0% 28.6% 25.0% 25.6% 26.5% 23.7% 21.4% 21.3% 31.7% 24.7% 22.4% 21.3% 0% Lakeland Miami Orlando Palm Bay Tampa Florida Nation DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING LONG-ACTING BASAL CATEGORY 1 VS. CATEGORY 2, BY A1c LEVEL RANGE, % % % >9.0% Cat. 1 Cat. 2 Cat. 1 Cat. 2 Cat. 1 Cat. 2 Cat. 1 Cat. 2 Lakeland 24.5% n/a 21.2% n/a 19.2% n/a 35.2% n/a Miami % % % % Orlando Palm Bay 25.2 n/a 29.7 n/a 18.0 n/a 27.0 n/a Tampa Florida NATION 24.3% 19.7% 21.8% 21.5% 21.0% 22.6% 32.9% 36.2% 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. 3 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. NOTE: Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after Category 2 refers to non-follow-on long-acting basal insulins approved in or after An n/a indicates that data were not available. MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

6 CHARGES PROFESSIONAL CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, Ambulatory Surgery Emergency Department Office/ Clinic Lakeland $2,141 $2,189 $1,862 $2,104 $3,590 $3,145 $1,467 $1,283 $2,811 $2,477 Miami 2,670 2,638 2,306 2,434 3,841 3,710 1,709 1,638 2,206 1,960 Orlando 2,346 2,471 2,023 2,385 4,087 3,895 1,746 1,631 1,869 1,756 Palm Bay 2,383 2,459 1,908 2,152 3,429 3,246 1,558 1,487 2,130 2,174 Tampa 2,492 2,504 1,887 1,831 3,935 3,621 1,708 1,707 2,222 2,029 Florida 2,487 2,534 2,024 2,167 3,671 3,526 1,586 1,582 2,163 2,006 NATION $2,599 $2,658 $1,549 $1,646 $3,512 $3,549 $1,420 $1,456 $2,100 $2,084 PROFESSIONAL INPATIENT CHARGES PER TYPE 2 DIABETES PATIENT PER YEAR, BY PAYER, Commercial Insurance 2 Medicaid Medicare Lakeland $3,125 $3,484 $3,673 Miami 3,721 3,634 3,641 Orlando 3,919 3,249 3,288 Palm Bay 3,141 3,287 3,030 Tampa 3,621 3,829 3,708 Florida 3,535 3,516 3,386 NATION $3,546 $3,837 $3,219 FACILITY CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, Lakeland $53,835 $43,766 n/a $9,065 Miami 41,099 44,339 $13,164 15,744 Orlando 46,350 54,299 13,573 15,151 Palm Bay 38,291 34,279 22,179 13,983 Tampa 48,039 45,184 15,073 15,539 Florida 46,668 47,203 15,184 15,543 NATION $43,804 $44,951 $11,784 $12,530 1 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 2 Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. 3 Figures reflect the charges generated by the facilities that delivered care. The data also reflect the amounts charged, not the amounts paid. NOTE: An n/a indicates that data were not available. 6 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

7 PHARMACOTHERAPY PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS INSULIN AND COMBINATION THERAPIES, Any Insulin Products Long-Acting Insulin Rapid-Acting Insulin GLP-1 + Long-Acting Insulin (Fixed Ratio) GLP-1 + Long-Acting Insulin (Free Ratio) Lakeland 29.8% 34.3% 20.5% 24.3% 12.0% 14.3% n/a 0.3% 2.2% 3.6% Miami n/a Orlando n/a Palm Bay n/a Tampa n/a Florida n/a NATION 33.9% 34.4% 24.3% 25.1% 17.2% 17.4% n/a 0.4% 2.9% 3.6% PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS INSULIN AND COMBINATION THERAPIES, PENS VS. VIALS, Long-Acting Basal Category 1 Long-Acting Basal Category 2 Rapid-Acting Insulin GLP-1 + Long-Acting Insulin (Fixed Ratio) Pens Vials Pens Pens Vials Pens Lakeland 14.0% 7.0% 5.3% 7.7% 7.6% 0.3% Miami Orlando Palm Bay Tampa Florida NATION 16.4% 5.0% 5.8% 10.9% 7.5% 0.4% PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS NON-INSULIN ANTIDIABETIC THERAPIES, Any Non-Insulin Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1 Receptor Agonists Lakeland 89.2% 87.6% 64.1% 61.4% 9.4% 8.7% 8.1% 10.1% Miami Orlando Palm Bay Tampa Florida NATION 85.5% 85.5% 60.5% 60.6% 10.8% 11.0% 9.6% 11.2% Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. GLP-1 Receptor Agonists: Increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite. GLP-1 + long-acting insulin (fixed ratio) refers to the two therapies combined in a single product. GLP-1 + long-acting insulin (free ratio) refers to the two therapies taken separately and concurrently. Insulin Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting Basal Category 1/Category 2: Insulin replacement product with a long duration of action. Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after Category 2 refers to non-follow-on long-acting basal insulins approved in or after Rapid-Acting Insulin: Insulin replacement product with a rapid onset and shorter duration of action than short-acting insulin. 1 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. NOTE: An n/a indicates that data were not available. MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

8 TYPE 2 DIABETES PATIENTS WITH DEPRESSION PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS WITH A COMORBIDITY OF DEPRESSION, % 12% 8% 4% 13.0% 12.7% 14.0% 11.7% 12.6% 13.1% 10.6% 10.7% 11.0% 10.0% 10.5% 10.9% 13.4% 13.7% 14.8% % 11.7% 12.2% 9.9% 10.0% 10.2% 0% Lakeland Miami Orlando Palm Bay Tampa Florida Nation DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMORBIDITY OF DEPRESSION, BY A1c LEVEL RANGE, ,2 7.0% % % >9.0% Lakeland 55.6% 56.1% 17.7% 15.4% 12.6% 13.5% 14.0% 15.1% Miami Orlando Palm Bay 56.7 n/a 18.9 n/a 10.4 n/a 14.0 n/a Tampa Florida NATION 53.4% 56.4% 19.6% 17.1% 12.5% 11.6% 14.5% 14.9% PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS THERAPIES, OVERALL VS. WITH A COMORBIDITY OF DEPRESSION, ,3 Any Insulin Products Long-Acting Insulin Any Non-Insulin Antidiabetic Product DPP-4 Inhibitors GLP-1 + Long-Acting Insulin (Free Ratio) Lakeland 34.3% 36.9% 24.3% 28.3% 87.6% 85.2% 8.7% 9.1% 3.6% 3.1% Miami Orlando Palm Bay n/a Tampa Florida NATION 34.4% 39.4% 25.1% 28.9% 85.5% 83.8% 11.0% 10.4% 3.6% 4.2% Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. GLP-1 Receptor Agonists: Increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite. GLP-1 + long-acting insulin (fixed ratio) refers to the two therapies combined in a single product. GLP-1 + long-acting insulin (free ratio) refers to the two therapies taken separately and concurrently. Insulin Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting Basal Category 1/Category 2: Insulin replacement product with a long duration of action. Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after Category 2 refers to non-follow-on long-acting basal insulins approved in or after Rapid-Acting Insulin: Insulin replacement product with a rapid onset and shorter duration of action than short-acting insulin. 1 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, depression, hyperlipidemia, hypertension, obesity, and pneumonia. 2 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 3 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. NOTE: An n/a indicates that data were not available. 8 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

9 TYPE 2 DIABETES PATIENTS WITH DEPRESSION PERSISTENCY: COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMORBIDITY OF DEPRESSION, VARIOUS THERAPIES, FLORIDA, % 88% 76% 64% 52% Long-Acting Basal Category 1: Long-Acting Basal Category 2: DPP-4 Inhibitors: GLP-1 Receptor Agonists: Mo. 1 Mo. 3 Mo. 6 PROFESSIONAL CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMORBIDITY OF DEPRESSION, ,2 Ambulatory Surgery Emergency Department Office/ Clinic Lakeland $2,189 $2,228 $2,104 $2,662 $3,145 $4,002 $1,283 $1,386 $2,477 $3,050 Miami 2,638 2,679 2,434 3,223 3,710 4,356 1,638 1,799 1,960 2,454 Orlando 2,471 2,470 2,385 3,063 3,895 4,471 1,631 1,837 1,756 2,182 Palm Bay 2,459 2,561 2,152 3,030 3,246 3,427 1,487 1,524 2,174 3,096 Tampa 2,504 2,762 1,831 2,184 3,621 3,988 1,707 1,874 2,029 2,464 Florida 2,534 2,667 2,167 2,763 3,526 4,122 1,582 1,767 2,006 2,503 NATION $2,658 $2,748 $1,646 $2,082 $3,549 $4,411 $1,456 $1,685 $2,084 $2,756 FACILITY CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMORBIDITY OF DEPRESSION, ,3 $70,000 $67,137 Annual Facility Charges $52,500 $35,000 $17,500 $54,299 $31,358 $40,305 $43,766 $44,339 $34,279 $41,088 $49,795 $47,203 $47,226 $45,184 $44,951 $9,065 $16,238 $19,308 $16,964 $15,744 $15,151 $13,983 $21,358 $17,474 $15,539 $15,543 $14,384 $12,530 $0 n/a Lakeland Miami Orlando Palm Bay Tampa Florida Nation Lakeland Miami Orlando Palm Bay Tampa Florida Nation n/a 1 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, depression, hyperlipidemia, hypertension, obesity, and pneumonia. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 3 Figures reflect the charges generated by the facilities that delivered care. The data also reflect the amounts charged, not the amounts paid. NOTE: Persistency measures whether patients maintain their prescribed therapy. It is calculated by identifying patients who filled a prescription for the reported drug class in the six months prior to the reported year, and then tracking prescription fills for those same patients in each of the months in the current reported year. If patients fill a prescription in a month, they are reported among the patients who have continued or restarted on therapy. Continued means that the patient has filled the drug group in each of the preceding months. Restarted means that the patient did not fill in one or more of the preceding months. Continuing and restarting patients are reported together. Persistency is tracked for patients who are new to therapy (those who have not filled the therapy in question in the six months prior to their first fill of the study period). An n/a indicates that data were not available. MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

10 TYPE 2 DIABETES PATIENTS WITH CV DISEASE PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS WITH A COMPLICATION OF CV DISEASE, % 39% 26% 13% 47.7% 47.5% 45.2% 47.3% 41.1% 40.3% 45.2% 41.2% 40.0% 42.9% 38.9% 35.6% 48.5% 43.2% 43.5% 46.1% 42.0% 41.4% % 37.2% 36.9% 0% Lakeland Miami Orlando Palm Bay Tampa Florida Nation DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMPLICATION OF CV DISEASE, BY A1c LEVEL RANGE, ,2 7.0% % % >9.0% CV CV CV CV Lakeland 55.6% 59.7% 17.7% 17.2% 12.6% 11.3% 14.0% 11.7% Miami Orlando Palm Bay Tampa Florida NATION 53.4% 55.0% 19.6% 19.5% 12.5% 12.5% 14.5% 13.1% PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS THERAPIES, OVERALL VS. WITH A COMPLICATION OF CV DISEASE, ,3 Any Insulin Products CV Long-Acting Insulin CV Any Non-Insulin Antidiabetic Product CV DPP-4 Inhibitors CV GLP-1 + Long-Acting Insulin (Free Ratio) Lakeland 34.3% 37.0% 24.3% 26.5% 87.6% 86.9% 8.7% 10.4% 3.6% 3.5% Miami Orlando Palm Bay Tampa Florida CV NATION 34.4% 40.0% 25.1% 29.7% 85.5% 84.0% 11.0% 12.0% 3.6% 3.8% Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. GLP-1 Receptor Agonists: Increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite. GLP-1 + long-acting insulin (fixed ratio) refers to the two therapies combined in a single product. GLP-1 + long-acting insulin (free ratio) refers to the two therapies taken separately and concurrently. Insulin Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting Basal Category 1/Category 2: Insulin replacement product with a long duration of action. Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after Category 2 refers to non-follow-on long-acting basal insulins approved in or after Rapid-Acting Insulin: Insulin replacement product with a rapid onset and shorter duration of action than short-acting insulin. 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, atherosclerotic cardiovascular disease (ASCVD; includes patients with ACS, MI, stroke, and other cardiovascular conditions), cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), retinopathy, severe hypoglycemia, and stroke. 2 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 3 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 10 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

11 TYPE 2 DIABETES PATIENTS WITH CV DISEASE PERSISTENCY: COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMPLICATION OF CV DISEASE, VARIOUS THERAPIES, FLORIDA, % 89% 78% 67% 56% Long-Acting Basal Category 1: Long-Acting Basal Category 2: DPP-4 Inhibitors: GLP-1 Receptor Agonists: CV CV CV CV Mo. 1 Mo. 3 Mo. 6 PROFESSIONAL CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMPLICATION OF CV DISEASE, ,2 Ambulatory Surgery CV Emergency Department CV CV CV Office/ Clinic CV Lakeland $2,189 $2,207 $2,104 $2,491 $3,145 $3,770 $1,283 $1,426 $2,477 $3,371 Miami 2,638 2,761 2,434 2,863 3,710 4,618 1,638 1,812 1,960 2,674 Orlando 2,471 2,433 2,385 2,883 3,895 4,655 1,631 1,725 1,756 2,252 Palm Bay 2,459 2,601 2,152 2,502 3,246 3,966 1,487 1,678 2,174 3,220 Tampa 2,504 2,624 1,831 2,014 3,621 4,272 1,707 1,845 2,029 2,646 Florida 2,534 2,629 2,167 2,500 3,526 4,264 1,582 1,732 2,006 2,682 NATION $2,658 $2,768 $1,646 $1,959 $3,549 $4,444 $1,456 $1,704 $2,084 $2,954 FACILITY CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMPLICATION OF CV DISEASE, ,3 $70,000 $34,279 $67,950 $65,366 CV Annual Facility Charges $52,500 $35,000 $17,500 $54,299 $44,085 $49,360 $43,766 $44,339 $45,184 $47,203 $44,951 $52,205 $50,152 $49,033 $9,065 $4,788 $15,744 $15,151 $21,134 $22,780 $13,983 $15,543 $12,530 $21,679 $11,580 $19,711 $15,539 $16,230 $0 Lakeland Miami Orlando Palm Bay Tampa Florida Nation Lakeland Miami Orlando Palm Bay Tampa Florida Nation 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, atherosclerotic cardiovascular disease (ASCVD; includes patients with ACS, MI, stroke, and other cardiovascular conditions), cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), retinopathy, severe hypoglycemia, and stroke. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 3 Figures reflect the charges generated by the facilities that delivered care. The data also reflect the amounts charged, not the amounts paid. NOTE: Persistency measures whether patients maintain their prescribed therapy. It is calculated by identifying patients who filled a prescription for the reported drug class in the six months prior to the reported year, and then tracking prescription fills for those same patients in each of the months in the current reported year. If patients fill a prescription in a month, they are reported among the patients who have continued or restarted on therapy. Continued means that the patient has filled the drug group in each of the preceding months. Restarted means that the patient did not fill in one or more of the preceding months. Continuing and restarting patients are reported together. Persistency is tracked for patients who are new to therapy (those who have not filled the therapy in question in the six months prior to their first fill of the study period). MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

12 TYPE 2 DIABETES PATIENTS WITH OBESITY PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS WITH A COMORBIDITY OF OBESITY, % 46.5% % 26% 13% 37.3% 37.1% 27.2% 28.4% 25.0% 27.5% 29.8% 27.5% 31.0% 33.9% 34.3% 35.4% 34.7% 28.1% 29.6% 30.7% 20.9% 23.3% 25.5% 0% Lakeland Miami Orlando Palm Bay Tampa Florida Nation DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMORBIDITY OF OBESITY, BY A1c LEVEL RANGE, ,2 7.0% % % >9.0% Obesity Obesity Obesity Obesity Lakeland 55.6% 55.9% 17.7% 17.7% 12.6% 11.6% 14.0% 14.8% Miami Orlando Palm Bay Tampa Florida NATION 53.4% 53.5% 19.6% 19.3% 12.5% 12.5% 14.5% 14.7% PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS THERAPIES, OVERALL VS. WITH A COMORBIDITY OF OBESITY, ,3 Any Insulin Products Long-Acting Insulin Any Non-Insulin Antidiabetic Product DPP-4 Inhibitors GLP-1 + Long-Acting Insulin (Free Ratio) Obesity Obesity Obesity Obesity Obesity Lakeland 34.3% 31.0% 24.3% 23.4% 87.6% 92.8% 8.7% 8.2% 3.6% 4.9% Miami Orlando Palm Bay Tampa Florida NATION 34.4% 31.5% 25.1% 24.2% 85.5% 91.2% 11.0% 11.5% 3.6% 5.0% Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. GLP-1 Receptor Agonists: Increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite. GLP-1 + long-acting insulin (fixed ratio) refers to the two therapies combined in a single product. GLP-1 + long-acting insulin (free ratio) refers to the two therapies taken separately and concurrently. Insulin Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting Basal Category 1/Category 2: Insulin replacement product with a long duration of action. Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after Category 2 refers to non-follow-on long-acting basal insulins approved in or after Rapid-Acting Insulin: Insulin replacement product with a rapid onset and shorter duration of action than short-acting insulin. 1 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, depression, hyperlipidemia, hypertension, obesity, and pneumonia. 2 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 3 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 12 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

13 TYPE 2 DIABETES PATIENTS WITH OBESITY PERSISTENCY: COMORBIDITY TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMORBIDITY OF OBESITY, VARIOUS THERAPIES, FLORIDA, % Long-Acting Basal Category 1: Long-Acting Basal Category 2: DPP-4 Inhibitors: GLP-1 Receptor Agonists: Obesity Obesity Obesity Obesity 89% 78% 67% 56% Mo. 1 Mo. 3 Mo. 6 PROFESSIONAL CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMORBIDITY OF OBESITY, ,2 Ambulatory Surgery Emergency Department Office/ Clinic Obesity Obesity Obesity Obesity Obesity Lakeland $2,189 $2,111 $2,104 $2,180 $3,145 $3,553 $1,283 $1,381 $2,477 $3,122 Miami 2,638 2,672 2,434 2,624 3,710 4,094 1,638 1,790 1,960 2,325 Orlando 2,471 2,546 2,385 2,268 3,895 4,145 1,631 1,702 1,756 1,943 Palm Bay 2,459 2,617 2,152 2,075 3,246 3,218 1,487 1,653 2,174 2,337 Tampa 2,504 2,538 1,831 1,848 3,621 3,758 1,707 1,744 2,029 2,267 Florida 2,534 2,557 2,167 2,234 3,526 3,802 1,582 1,694 2,006 2,321 NATION $2,658 $2,642 $1,646 $1,714 $3,549 $3,898 $1,456 $1,599 $2,084 $2,500 Annual Facility Charges $56,000 $42,000 $28,000 $14,000 $43,048 $43,766 $44,339 $46,701 FACILITY CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMORBIDITY OF OBESITY, ,3 $49,889 $54,299 $34,279 $45,184 $51,310 $47,203 $49,726 $44,951 $45,142 $7,477 $9,065 $15,744 $19,568 $15,075 $15,151 $13,983 $22,622 $15,539 $17,265 $15,543 $16,381 Obesity $12,603 $12,530 $0 n/a Lakeland Miami Orlando Palm Bay Tampa Florida Nation Lakeland Miami Orlando Palm Bay Tampa Florida Nation 1 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, depression, hyperlipidemia, hypertension, obesity, and pneumonia. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 3 Figures reflect the charges generated by the facilities that delivered care. The data also reflect the amounts charged, not the amounts paid. NOTE: Persistency measures whether patients maintain their prescribed therapy. It is calculated by identifying patients who filled a prescription for the reported drug class in the six months prior to the reported year, and then tracking prescription fills for those same patients in each of the months in the current reported year. If patients fill a prescription in a month, they are reported among the patients who have continued or restarted on therapy. Continued means that the patient has filled the drug group in each of the preceding months. Restarted means that the patient did not fill in one or more of the preceding months. Continuing and restarting patients are reported together. Persistency is tracked for patients who are new to therapy (those who have not filled the therapy in question in the six months prior to their first fill of the study period). An n/a indicates that data were not available. MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

14 TYPE 2 DIABETES PATIENTS WITH NEUROPATHY PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS WITH A COMPLICATION OF NEUROPATHY, % 40.6% 43.3% 45.4% 43.5% 44.2% 40.6% 40.3% 42.4% 42.5% 43.7% 37.4% 36.9% 38.2% 40.1% 40.2% 40.8% 37.7% 36% 33.5% 33.3% 35.8% 36.2% 24% 12% 0% Lakeland Miami Orlando Palm Bay Tampa Florida Nation DISTRIBUTION OF COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMPLICATION OF NEUROPATHY, BY A1c LEVEL RANGE, ,2 7.0% % % >9.0% Lakeland 55.6% 51.5% 17.7% 18.2% 12.6% 14.2% 14.0% 16.2% Miami Orlando Palm Bay Tampa Florida NATION 53.4% 49.2% 19.6% 20.0% 12.5% 13.9% 14.5% 16.9% PERCENTAGE OF COMMERCIAL TYPE 2 DIABETES PATIENTS RECEIVING VARIOUS THERAPIES, OVERALL VS. WITH A COMPLICATION OF NEUROPATHY, ,3 Any Insulin Products Long-Acting Insulin Any Non-Insulin Antidiabetic Product DPP-4 Inhibitors GLP-1 + Long-Acting Insulin (Free Ratio) Lakeland 34.3% 45.4% 24.3% 32.9% 87.6% 85.4% 8.7% 8.2% 3.6% 5.7% Miami Orlando Palm Bay Tampa Florida NATION 34.4% 48.1% 25.1% 35.5% 85.5% 80.7% 11.0% 11.1% 3.6% 5.1% Biguanides: Decrease the production of glucose by the liver, decrease intestinal absorption of glucose, and increase the peripheral uptake and use of circulating glucose. Dipeptidyl Peptidase 4 (DPP-4) Inhibitors: Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels. GLP-1 Receptor Agonists: Increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite. GLP-1 + long-acting insulin (fixed ratio) refers to the two therapies combined in a single product. GLP-1 + long-acting insulin (free ratio) refers to the two therapies taken separately and concurrently. Insulin Sensitizing Agents: Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose. Long-Acting Basal Category 1/Category 2: Insulin replacement product with a long duration of action. Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after Category 2 refers to non-follow-on long-acting basal insulins approved in or after Rapid-Acting Insulin: Insulin replacement product with a rapid onset and shorter duration of action than short-acting insulin. 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, atherosclerotic cardiovascular disease (ASCVD; includes patients with ACS, MI, stroke, and other cardiovascular conditions), cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), retinopathy, severe hypoglycemia, and stroke. 2 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year. 3 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 14 FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES

15 TYPE 2 DIABETES PATIENTS WITH NEUROPATHY PERSISTENCY: COMMERCIAL TYPE 2 DIABETES PATIENTS, OVERALL VS. WITH A COMPLICATION OF NEUROPATHY, VARIOUS THERAPIES, FLORIDA, % Long-Acting Basal Category 1: Long-Acting Basal Category 2: DPP-4 Inhibitors: GLP-1 Receptor Agonists: 89% 78% 67% 56% Mo. 1 Mo. 3 Mo. 6 PROFESSIONAL CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMPLICATION OF NEUROPATHY, ,2 Ambulatory Surgery Emergency Department Office/ Clinic Lakeland $2,189 $2,412 $2,104 $2,235 $3,145 $3,794 $1,283 $1,336 $2,477 $2,996 Miami 2,638 2,693 2,434 2,729 3,710 4,473 1,638 1,798 1,960 2,343 Orlando 2,471 2,557 2,385 2,687 3,895 4,626 1,631 1,739 1,756 2,023 Palm Bay 2,459 2,655 2,152 2,457 3,246 3,949 1,487 1,585 2,174 2,851 Tampa 2,504 2,640 1,831 1,996 3,621 4,145 1,707 1,910 2,029 2,438 Florida 2,534 2,650 2,167 2,452 3,526 4,256 1,582 1,755 2,006 2,451 NATION $2,658 $2,780 $1,646 $1,922 $3,549 $4,435 $1,456 $1,731 $2,084 $2,828 Annual Facility Charges $64,000 $48,000 $32,000 $16,000 $0 $43,766 $62,615 FACILITY CHARGES PER COMMERCIAL TYPE 2 DIABETES PATIENT PER YEAR, OVERALL VS. WITH A COMPLICATION OF NEUROPATHY, ,3 $45,890 $57,298 $44,339 $54,299 $34,279 n/a $45,184 $50,587 $47,203 $51,864 $44,951 $49,467 $9,065 $6,044 $15,151 $13,983 $15,539 $15,543 $21,881 $12,530 $18,656 $19,609 $17,450 $18,562 $15,744 $15,572 Lakeland Miami Orlando Palm Bay Tampa Florida Nation Lakeland Miami Orlando Palm Bay Tampa Florida Nation 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, atherosclerotic cardiovascular disease (ASCVD; includes patients with ACS, MI, stroke, and other cardiovascular conditions), cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), retinopathy, severe hypoglycemia, and stroke. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 3 Figures reflect the charges generated by the facilities that delivered care. The data also reflect the amounts charged, not the amounts paid. NOTE: Persistency measures whether patients maintain their prescribed therapy. It is calculated by identifying patients who filled a prescription for the reported drug class in the six months prior to the reported year, and then tracking prescription fills for those same patients in each of the months in the current reported year. If patients fill a prescription in a month, they are reported among the patients who have continued or restarted on therapy. Continued means that the patient has filled the drug group in each of the preceding months. Restarted means that the patient did not fill in one or more of the preceding months. Continuing and restarting patients are reported together. Persistency is tracked for patients who are new to therapy (those who have not filled the therapy in question in the six months prior to their first fill of the study period). An n/a indicates that data were not available. MANAGED CARE DIGEST SERIES FLHCC FLORIDA TYPE 2 DIABETES REPORT,

16 METHODOLOGY/ADA GUIDELINES 5703 Red Bug Lake Rd #118 Winter Springs, Florida Phone: Fax: METHODOLOGY IQVIA generated most of the data for this report out of health care professional (837p) and institutional (837i) insurance claims, representing nearly 11.7 million unique patients nationally in 2017 with a diagnosis of Type 2 diabetes (E08, E09, E11, E13; data in 2015 include ICD-9 codes , and ICD-10 codes E08, E09, E11, E13). Data from physicians of all specialties and from all hospital types are included. Substate markets represent core-based statistical areas (CBSAs). IQVIA also gathers data on prescription activity from the National Council for Prescription Drug Programs (NCPDP). These data account for some 2 billion prescription claims annually, or more than 86% of the prescription universe. These prescription data represent the sampling of prescription activity from a variety of sources, including retail chains, mass merchandisers, and pharmacy benefit managers. Cash, Medicaid, and third-party transactions are tracked. Proprietary lab data derive from one of the largest independent commercial lab companies in the U.S. Patient information is de-identified, matched, and linked with other patient data assets (e.g., medical claims data). The most common attributes used are the de-identified patient ID, observation date, diagnosis, test name, test code, and test result. DATA INTEGRITY Data arriving into IQVIA are put through a rigorous process to ensure that data elements match to valid references, such as product codes, ICD-9/10 (diagnosis) and CPT-4 (procedure) codes, and provider and facility data. Claims undergo a careful de-duplication process to ensure that when multiple, voided, or adjusted claims are assigned to a patient encounter, they are applied to the database, but only for a single, unique patient. Through its patient encryption methods, IQVIA creates a unique, random numerical identifier for every patient, and then strips away all patient-specific health information that is protected under the Health Insurance Portability and Accountability Act (HIPAA). The identifier allows IQVIA to track diseasespecific diagnosis and procedure activity across the various settings where patient care is provided (hospital inpatient, hospital outpatient, emergency rooms, clinics, doctors offices, and pharmacies), while protecting the privacy of each patient ADA Guidelines for Adults With Type 2 Diabetes At diagnosis, initiate lifestyle management, set A1c target, and initiate pharmacologic therapy based on A1c: A1c is less than 9%, consider Monotherapy. A1c is greater than or equal to 9%, consider Dual Therapy. A1c is greater than or equal to 10%, blood glucose is greater than or equal to 300 mg/dl, or patient is markedly symptomatic, consider Combination Injectable Therapy. MONOTHERAPY Lifestyle Management + Metformin Initiate metformin therapy if no contraindications A1c at target after 3 months of Monotherapy? Yes: Monitor A1c every 3 6 months No: Assess medication-taking behavior, consider Dual Therapy DUAL THERAPY Lifestyle Management + Metformin + Additional Agent Atherosclerotic cardiovascular disease (ASCVD)? Yes: Add agent proven to reduce major adverse cardiovascular events and/or cardiovascular mortality* No: Add second agent after consideration of drug-specific effects and patient factors A1c at target after 3 months of Dual Therapy? Yes: Monitor A1c every 3 6 months No: Assess medication-taking behavior, consider Triple Therapy TRIPLE THERAPY Lifestyle Management + Metformin + Two Additional Agents Add third agent based on drug-specific effects and patient factors # COMBINATION INJECTABLE THERAPY A1c at target after 3 months of Triple Therapy? Yes: Monitor A1c every 3 6 months No: Assess medication-taking behavior, consider Combination Injectable Therapy * If patient does not tolerate or has contraindications to metformin, consider agents from another class. # Glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase 4 (DPP-4) Inhibitors should not be prescribed in combination. If a patient with ASCVD is not yet on an agent with evidence of cardiovascular risk reduction, consider adding. NOTE: A1c is glycated hemoglobin. Source: American Diabetes Association Standards of Care 2018;41:S73 S85 Sanofi U.S. LLC, as sponsor of this report, maintains an arm s-length relationship with the organizations that prepare the report and carry out the research for its contents. The desire of Sanofi U.S. is that the information in this report be completely independent and objective sanofi-aventis U.S. LLC, A SANOFI COMPANY SAUS FLHCC FLORIDA TYPE 2 DIABETES REPORT, 2018 MANAGED CARE DIGEST SERIES