Wednesday, September 23, 2020

More Games With U.S. Insulin Prices and Coupons (or why GoodRx works)

This week, I did something unplanned: I bought a vial of Lilly's "authorized generic" of its brand-name U-100 insulin analog usually branded as Humalog (insulin lispro rDNA origin) at my neighborhood Walgreens for just $68.38! The reason it was unplanned is because I already met the deductible for my insurance plan, so I hadn't expected to deal with this until it resets in January (maybe, I think my new plan covers it without having met the deductible but we'll see). But I had a script I last filled before I met the deductible, and the pharmacy sent a text telling me it was time to refill. In reality, I have insulin but its a different brand and a different pharmacy. But Walgreens wants a sale so it was telling me it is time to refill. I had a coupon to get it for a price comparable to what it sells for in Europe, Canada and elsewhere and I wanted to see if it really worked. It did!

According to insulin manufacturer Eli Lilly & Company, Inc. the price of its "authorized generic" of U-100 insulin lispro product is supposedly half-price of the "list price" for the branded version known as Humalog (U-100 insulin lispro rDNA origin). Both are made by Lilly. I bought it since I was able to get it for >$30 less than I had paid out-of-pocket last time (and that was a big discount without insurance), and I wanted to ensure I really could pay that price for insulin, and I discovered it worked!

According to the Lilly press release, the list price for a vial of the "authorized generic" version of Humalog is $137.35 per vial which it asserts is half-price. Back-of-the-envelope math means that the price for a vial of the brand-name version of the product known as Humalog should theoretically be $274.70 per vial. I don't know if that's truly the price, when I was paying for it out-of-pocket, I actually paid MORE than that amount, at least once. I now have a different insurance plan (its become an almost annual tradition, which means I've been covered by Aetna, Anthem, Cigna, Emblem Health, and United Healthcare over the past few years, and each time it means non-medical switching to whichever insulin brand pays the insurance company the most money in rebates). But that was WITH an insurance card. Truth be told, I stopped paying for insulin through insurance when I was paying my deductible because not only did my insurance give me less credit applied towards my deductible than I actually paid, but I also discovered that I could pay LESS for the product, too -- meaning only a fool pays that price. 

But it also raises big questions about what the real price for insulin sold in the U.S. actually is?

If you're paying out-of-pocket, the prices become even more obfuscated and they're already pretty hidden with insurance. That means either someone isn't being truthful, or even when patients are in deductible phase, many are actually being overcharged for the product. We know that most of that money is benefiting insurance plan sponsors (employers) who pay premiums for insurance plans. That's because most insurance plans pass 90% or  100% of Rx rebates they receive onto plan sponsors who take that money as an offset to premiums without considering who's actually bankrolling that. After all, its not THEIR money, so it costs insurance nothing to give it to employers in order to sell a new insurance policy.

In reality, $137.35 may not be quite a half-price for a vial of the brand-name product of Humalog insulin. Because no one ever discloses what the true price really is, so we're left to take the word of parties who have never been exactly truthful about prices. However, I discovered that with GoodRx, the price patients pay was $68.38/vial at my local Walgreens, which I think is actually about half-price. (Although rival Novo Nordisk has also promised a half-price version of its rapid-acting insulins, so far, their cheaper products are not yet widely available). The reason I think GoodRx's $68.38 is probably the true half-price is according to an article written by  Dr. Elisabeth Rosenthal (now the editor-in-chief at Kaiser Health News, and author of "An American Sickness: How Healthcare Became Big Business and How You Can Take it Back") when Lilly announced its half-price "authorized generic" earlier this year, she wrote "In Germany, the list price of a vial of Humalog is about $55 — or $45 if you buy 5 at a time — and that includes some taxes and markup fees." Therefore, Americans shouldn't feel grateful for $137 Insulin.

But in order for me to even get that price, I needed a coupon. As it turns out, there are a variety of different coupons available — you just need to know where to get them. The only thing is you cannot fill a script for Lilly's "authorized generic" of insulin lispro at a CVS Pharmacy because that company simply refuses to even carry it. The reason is because it makes too much money on the rebates paid on the brand-name product.

Fortunately, I asked my doctor to write the script for a vial of "insulin lispro" which I initially filled for with Sanofi's Humalog biosimilar known as Admelog (I went to Walgreens, not CVS because there's one closer to where I live, and in the midst of the Covid-19 pandemic in NYC, I could simply walk around the corner and wait in line for 3 hours) because I had a coupon to get it for $99.00 per vial, which was vastly cheaper than the alternatives (at least at the time; today there are alternatives). My experience with using Admelog was very good; I did not have to make any adjustments to insulin-to-carb or correction ratios, so in my opinion, that was as close to interchangeable as it comes. 

By comparison, with "therapeutically equivalent" products such as Novo Nordisk insulin aspart (branded as either Novolog or Fiasp) or Sanofi's Apridra (U-100 insulin glulisine rDNA origin), that never happens. It always requires me to test and test again to come up with brand new ratios. Of course, insurance never provides any additional test strips when doing a non-medical brand switch of this type, which they should. Plus the product never works quite the same as the one it replaces. The peak hits at different times, and the "tail" lasts for different durations. Today, my insurance only covers Novo Nordisk insulin varieties, so I've been using Fiasp. Fortunately, its a new plan which means insurance actually charges the copay amount to patients even still in deductible phase. They should be doing so; they are getting generous tax benefits from U.S. taxpayers via the IRS in order to do so.

Because my doctor wrote the script for "insulin lispro", I discovered Walgreens could fill my script with brand-name Lilly Humalog, Sanofi Admelog, or Lilly Lispro (the "authorized generic") and potentially others from companies like Mylan and co-development partner Biocon, as well as Novartis' Sandoz unit in the future — the difference is what price will be charged. With coupons, that's another layer to the murky price patients are charged. In the end, for this go-around, the pharmacist told me that with the coupon from GoodRx for the 'authorized' Lilly Lispro, I'd pay about $131.00 for 2 vials, which works out to be about $65.00/vial. GoodRx notes: "You may find that filling a 90-day supply will reduce your total cost for this prescription." But I bought just 1 for exactly $68.38 which was vastly different in price from what I would have paid without a coupon.

So, take your pick. But take my advice: don't dare pay full price for insulin if you can avoid it with an app like GoodRx. Almost no one does. Even if you're paying down towards a deductible, it will cost you less money to use one of the coupons than it will to buy it with insurance involved. Insurance only gives you credit for their deeply-discounted price applied towards your deductible amount. The only exception is when you're getting close to satisfying the deductible and need an insulin refill. That could push you towards satisfying the deductible amount (maybe).

For Sanofi's coupon, in order to get its $99.00/vial of Admelog (U-100 insulin lispro rDNA origin), you should visit Unlike many bogus "patient assistance programs" which hardly anyone qualifies for, you can actually get this discount coupon today. 

But you'll be asked to answer a few 'eligibility' questions. Just be sure to answer those questions correctly, or they could respond by telling you that you're somehow ineligible for the discount coupon. Don't believe it. They will ask you to answer the following questions; I've provided the answers you must give in order to get the coupon.

1. Are you a current resident of the United States, Puerto Rico, Guam, or the U.S. Virgin Islands? Answer "Yes" to this question (side-note: if you lived in any other place on earth, you would be paying a fraction of what you do in the U.S. and territories!).

2. Are you a patient 18 years of age or older? Answer "Yes" to this question.

3. Do you currently receive Medicaid? Answer "No" to this question.

4. Are you currently serving in the U.S. military? Answer "No" to this question.

5. Do you qualify for Medicare? Answer "No" to this question.

6. Do you have commercial/private insurance? Answer "No" to this question.

7. Do any of the following apply: 

  • You are 65 years of age or older and neither you nor your spouse is working, 
  • You are receiving Social Security payments because of a disability,  
  • You have end-stage renal disease 

Again, you must answer "No" to this question. 

Questions about serving in the U.S. military, or whether you're eligible for Medicaid or Medicare are irrelevant and Sanofi isn't really entitled to know that. Whether you qualify for any of those government insurance plans is not relevant to how you are actually PAYING for their insulin. The reason is because you will not be not using any of those to actually FILL your prescription, hence you are paying out-of-pocket and are therefore entitled to the discount offered with the coupon. 

GoodRx is different, but you should know about it. It's free. The company is a Los Angeles-based (technically, its based in the beach town of Santa Monica, but its still Los Angeles County) and recently filed paperwork with the Securities and Exchange Commission (SEC) in anticipation of becoming a publicly-traded company. Adam Fein, a consultant who runs the Drug Channels Institute, which is a consulting firm which makes money by advising clients (either pharmacy chains, drug manufacturers or drug distribution system entitites like PBM's and drug wholesalers) to maximize their own profits from the dysfunctional U.S. prescription drug system (the word "system" is a misnomer, but whatever) recently addressed GoodRx in a blog post. 

Adam Fein likes to refer to himself as a doctor, and technically-speaking that's true. But he has a PhD, not an MD which is a bit of misrepresentation of his actual qualifications. Self-important people tend to do that. Adam never went to med school and he's never taken any medical boards. Instead, he's more of a bean counter for an obscure niche of the U.S. healthcare system. I worked for a mathematician with a PhD for years, but she never called herself a doctor even in proposals because she felt it was misleading and didn't want to have to explain the reality that she knew absolutely nothing about medicine, so she just used her name. But Adam thinks you'll be more impressed when he calls himself Dr. Adam J. Fein. I could care less; but I do think his explanation about how GoodRx works is useful background info. He wrote a post called "How GoodRx Profits from Our Broken Pharmacy Pricing System" (see for more). 

He said: "The company [GoodRx] is insanely profitable. Its adjusted net income—earnings before interest, taxes, depreciation, and amortization (EBITDA)—is an astonishing 40%."

Fein summarizes the GoodRx revenue model as follows:

  1. Start with the pharmacy's bogus cash prescription price (YES, he used the word BOGUS, except its not bogus for many)
  2. Save money for consumers by providing easy access to a PBM's network rates (he adds: "GoodRx partners with multiple PBM's, including Express Scripts, OptumRx, MedImpact, and Navitus")
  3. Collect a portion of the fee that the pharmacy pays the PBM

He says "The GoodRx team has built and scaled a robust platform for monetizing the three steps above" adding "Think about it this way: GoodRx profits by helping consumers avoid the U.S. pharmacy industry's historical cash pricing models."

Fair enough. But the reality is that as long as the U.S. prescription drug market is so dysfunctional, it is up to the individual paying the bills to figure out how to help themselves navigate through it. For anyone trying to satisfy a healthcare insurance plan deductible, it means YOU are the one paying the bill for at least part of the year. And, because insulin happens to be one of the most heavily-rebated prescription medicines in existence, that means people with diabetes need to learn enough about it to avoid paying too much. As it turns out, Lilly's Insulin Lispro product can be attained at prices at least comparable to what people in places like Canada or Germany pay. 

Note that GoodRx also has a coupon for $71.72 at Walgreens for Novo Nordisk insulin aspart (which is the "authorized generic" version of Novolog). Its not quite as deeply-discounted as the "authorized generic" of Humalog is, but its a mere $3.34 more, so its only marginally more costly if you're a person who does better with Novo Nordisk's products rather than Lilly's. Note that there's no coupon for Fiasp. If you're struggling to pay for insulin, I'd say have your doctor prescribe insulin lispro because its cheaper, but I do think the coupons for either are a meaningful enough discount to help many patients as we head into the 2021 deductible reset.

Biosimilars are one option. Sanofi makes a version of Humalog and offers coupons to get that for $99.00/vial which isn't terrible. But GoodRx offers the so-called Lilly "Half-Priced" Humalog for $68.38, or the half-priced version of Novolog for $71.72. As of today, the Lilly version is the least-costly rapid-acting insulin analog GoodRx is offering at that price, but the prices are low enough to make a worthwhile difference as we head into 2021 and insurance deductibles reset. 

Long-acting insulin analog varieties such as Sanofi Lantus, or biosimilars of that known as Lilly Basaglar and Mylan and Biocon's Semglee seemed to be less-heavily discounted perhaps because it is so widely used by many patients with Type 2. That said, biosimilar copies of Lantus including Lilly's Basaglar or Semglee may offer coupons for even deeper discounts. In general, competition for the exact same insulin (for which, there are now at least 3 brands) tends to result in greater discounting.

Even amongst those, a seach for Semglee revealed GoodRx had coupons for a vial of that sold for $105.71 at several different pharmacies (not quite as discounted as the authorized generic version of Lilly Insulin Lispro, but most patients don't use as much basal insulin as they do insulin for bolus coverage of meals and corrections. By comparison, Lantus and Basaglar did not seem to offer as generous discount coupons at GoodRx (although the websites of those insulin brands may offer coupons). But that insulin is the one that will have the most biosimilar versions. There are currently two, but we know of at least two more in development from Sandoz and Lannett in the works. Typically, the more versions of the same product which exist, discounts and coupons are the way that competition manifests itself in the market.

Note that GoodRx has different coupons for use at different pharmacies in your geographic area and on different prescription drugs. I say lowest price wins, but I'll leave that decision up to you. It has a mobile app you can use in-store.

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