How to Navigate Life with a Chronic Disease Like T1D and High-Deductible Insurance - Redux

Last February (2021), I wrote a blog post called "How to Navigate Life with a Chronic Disease Like T1D and High-Deductible Insurance Plans" (read my post at https://blog.sstrumello.com/2021/02/how-to-navigate-life-with-chronic.html for details).

I still stand by all of the recommendations I made in that blog post because I actually used (and still use some) the methods described effectively and saved a lot of money by doing so. But times change, and sometimes strategies need to evolve with changes that happen in the world around us.

Intro of "Authorized Generic" Insulins, plus Branded/Unbranded Biosimilars

For example, in 2019 when both Lilly and Novo Nordisk each announced they would introduce less costly versions of their blockbuster rapid-acting insulin analogues to be sold at half-price in the U.S., savvy patients very quickly discovered that they could actually purchase Lilly Insulin Lispro or Novo Nordisk Insulin Aspart for about 75% off the bogus cash retail prices simply by presenting the pharmacist a GoodRx coupon, and voila: instant 75% savings. In fact, using the GoodRx method is actually cheaper than Walmart's Relion Novolog offering if patients buy the insulin at the lowest cost pharmacy in their area (which I blogged about HERE).

For example, by patronizing Walgreens, a patient can today buy a vial of Novo Nordisk Insulin Aspart for $58.83/vial compared to the company's co-branded Walmart Relion Novolog which retails currently for $72.88/vial. The GoodRx method is actually 19% less costly than buying a vial of Relion Novolog at Walmart. But that is still more costly than buying Lilly Insulin Lispro is. That said, there are a number of insulin aspart biosimilars (not so many of insulin lispro to my knowledge) in development which may ultimately lead to Novo Nordisk to eventually "retire" the product and market Fiasp instead. That could lead to only biosimilar-makers selling the product once branded as Novolog.

Lilly Reduced Price of Insulin Lispro by Another 40%

 

 

 

 

Anyway, since the 2019 move to introduce a less costly version known as Lilly Insulin Lispro, Lilly subsequently announced it would further reduce its price on Lilly Insulin Lispro by an additional 40% (see the Lilly press release at https://www.prnewswire.com/news-releases/lilly-again-reduces-list-price-of-insulin-lispro-injection-as-latest-change-to-affordability-options-301386117.html for full details) effective on January 1, 2022. Lilly's press release said that its Lilly Insulin Lispro would now sell for approximately 70% less than Lilly's branded U-100 Humalog insulin (the insulin is exactly the same, though it has a different NDC number, a different box and label, yet it is made on the exact same assembly line). Lilly execs have told investors that Lilly Insulin Lispro now accounts for at least 30% of Humalog sales in the U.S. Also, investor presentations show that Lilly Insulin Lispro accounts for most of the recent U.S. Humalog sales growth.

U.S. prescription drug prices have always been fuzzy because in the pharmaceutical industry, ALL of the price numbers are bogus. The list prices are bogus (unless you actually pay them), the discounts are undisclosed, hence no one really knows what the true prices really are or how big the discounts are, and the retail pharmacy has almost no control over the prices it charges due to their contracts with Pharmacy Benefits Managers ("PBM's"). The PBM makes all the decisions on prices, not the retail pharmacy. And, a pharmacy could not be in business without a contract with a PBM.

Finding Less Costly Lilly Insulin Lispro Isn't Easy

That said, obtaining the 40% less costly Lilly Insulin Lispro isn't as easy as just going to the pharmacy and asking the pharmacist for it. GoodRx won't get you the new 40% lower price, either (GoodRx are PBM coupons, and you need a drug manufacturer coupon for that). When Lilly Insulin Lispro hit the market in 2020, patients discovered they could buy that insulin for about 75% off the cash price by using a GoodRx coupon. Hence, the 2021 Lilly announcement of another price reduction initially looked to patients like more pharma smoke and mirrors. But, it actually IS possible to do better than that. The key is patients need a manufacturer coupon to be able to buy it for just $35/vial, which is a pretty decent price.

 

 

 

Earlier this year, Lilly very quietly launched something it calls the Lilly Insulin Value Program found at the website https://www.insulinaffordability.com/ which to my knowledge is the only site offering these manufacturer discount coupons. Whether a patient has commercial insurance or no insurance at all, the manufacturer coupons are the method to get that lower price. These coupons are direct from the manufacturer. With the Lilly Insulin Value Program, virtually anyone can freely download coupons to buy Lilly Insulin Lispro for a price of just $35/vial — virtually no screening for eligibility is required, and the manufacturer coupons can be downloaded instantly. 

My Canada Insulin-Buying Experience

For the record, I went to Montreal Canada in November 2021, and visited a pharmacy to buy a vial of Humalog (the pharmacy I patronized was Jean Coutu). The price I was charged to buy a vial of Humalog was $37.79 Canadian Dollars, so given the exchange rate, that equaled $30.02 in U.S. Dollars. The U.S. is getting closer to Canadian insulin prices, although we still aren't there yet.

 

 

 

 

 

 

 

Unlike Lilly's previous (and other) Patient Affordability Programs which required patients to provide lots and lots of personal financial info to the company so it could decide if a patient is even eligible (plus the decision was not made instantly, and there was no guarantee patients would even be eligible), the Lilly Insulin Value Program works differently. Virtually anyone can download a coupon instantly.

Lilly offers two coupons: one is for patients with commercial healthcare insurance, and it offers a different coupon for those cash-paying patients with no insurance at all. The price with both coupons is exactly the same, except that the two coupons helps Lilly to understand which insurance companies its insulin users are coming from. Many have insurance plans which "prefer" Novo Nordisk insulins, but the ones who "prefer" Lilly insulins are those which Lilly hopes to persuade to actually cover its insulin as a "preventative treatment" eligible for pre-deductible coverage in accordance with new IRS rules. Hence, that particular coupon requires the patient to present a valid insurance card in order to get the $35/vial price. 

Don't Shoot the Messenger!

Look, I understand some advocates decry the need for coupons from big insulin manufacturers. But the reality is that the U.S. prescription drug market is fundamentally broken, and in order to operate in that dysfunctional market, rebates are how drug companies market prescription drugs in the U.S. For the time being, we are stuck working within the broken system we live in. And, the most effective solution to the affordability problem right now is coupons. Please don't shoot the messenger!

For virtually ALL new, still patent-protected prescription drugs, I suggest patients should make themselves aware of what I call the "New Drug Rule" which is basically the only discounts patients are likely to get are directly from the drug manufacturers themselves, rather than the PBM coupons. 

My friend's mother uses a drug prescribed for irritable bowel syndrome (my mother lives with an autoimmune inflammatory bowel disease called Ulcerative Colitis, so I never really understood how IBS is different from IBD, but IBS is more mild than IBD) called Linzess (linaclotide) made by AbbVie, and it still enjoys patent exclusivity, so we found a manufacturer coupon enabling her to get that drug for as little as $30 with the Linzess Savings Program, a similar manufacturer coupon to Lilly's Insulin Value Program.Insured patients can, however, use the Lilly Insulin Value Program $35/vial for Lilly Insulin Lispro coupon intended for those who pay cash if the other does not work for some reason (but those cost Lilly more money, plus it does not help the company focus its marketing on insurance company plans which fail to cover its insulin pre-deductible).

Ignore the Big Health Insurance Myth: "Rx Purchases at an artificially-inflated cash price will reduce your deductible"

As for the other methods I described, the coupon route is a growing part of U.S. prescription affordability. Without a lengthy dialogue about coupons, as you might realize, there are manufacturer coupons, and then there are PBM coupons. Both manufacturer and PBM coupons offer deep Rx discounts, but it is important that patients ignore the myth (and it is a MYTH) that covered patients should not use coupons because they don't contribute towards satisfying a deductible. That is, at best, only a half-truth. The reality is patients only receive credit applied towards their deductibles for the deeply-discounted, PBM-negotiated prices, not the a artificially-inflated cash retail prices charged at the pharmacy checkout counter. That's a rip-off. Beware that not all manufacturers offer coupons on all drugs they sell, but when they do, the manufacturer discounts can be pretty good.

As for PBM coupons (all but the first are powered by one or more PBM's), they're hit or miss. I encourage my readers to search EACH of the following coupon-generating websites/apps:

SingleCare (which is the only website/app NOT powered by a PBM) https://www.singlecare.com/ 

GoodRx (powered by a combo of PBM's including: Cigna's Evernorth/Express Scripts, United Healthcare Group's OptumRx, Navitus which is a PBM owned by the nonprofit hospital chain SSM Health & Costco, and MedImpact Health Systems, Inc. which is de facto controlled by its single largest client Kaiser Permanente. Note that GoodRx only offers access to one formulary offered by each PBM, and each PBM offers different drug formularies including both high price/high rebate formularies, and low price/low rebate drug formularies which tends to favor generics; the single formulary access limits GoodRx's ability to always offer the lowest Rx drug prices) https://www.goodrx.com/ 

InsideRx (run by Cigna's Evernorth/Express Scripts PBM) https://www.insiderx.com/

OptumPerks (run by United Healthcare's OptumRx PBM) https://perks.optum.com/

ScriptSave WellRx (run by Kaiser Permanente's* PBM MedImpact) https://www.wellrx.com/ 

America's Pharmacy (run by Kaiser Permanente's* PBM MedImpact) https://www.americaspharmacy.com/ 

BlinkHealth (powered by Kaiser Permanente's* PBM MedImpact) https://www.blinkhealth.com/

ScriptHero (run by drug wholesaler McKesson, and powered by the company's own CoverMyMeds, plus SingleCare and WellRx) https://www.scripthero.com/ 

WellCardRx (run by the PBM WellDyne) https://wellcardrx.com/

*On April 20, 2022, there was news (see HERE for details) that Kaiser Permanente had signed a contract with Cigna's Evernorth/Express Script to provide various services, which will eventually include PBM services which are now provided by the PBM known as MedImpact. MedImpact's full PBM contract with Kaiser Permanente is officially up for renewal in 2023.

Capital Rx Advantage Savings https://capitalrxadvantage.com/ is a newcomer from a startup in the PBM space, but its cost-plus and unique business model occasionally offers unheard of prices, including on some overpriced generic drugs.

I recommend searching online using ALL of these coupon-generating websites/apps to find the lowest out-of-pocket cost for each prescription drug. I recommend investing an afternoon searching each prescription drug your household uses on a chronic basis and making the choice where to buy the drugs based on lowest prices and personal convenience.

Patients who use this shop-for-the-best-price method will not only save anywhere from 55% to 90% on Rx drug prices, plus because insurers give them only pennies on the dollar of what they pay at the pharmacy checkout, they should satisfy their deductible fairly close to the date they did when they paid outrageous cash retail prices for the same prescription drugs because of how little credit their insurance company applies towards their deductibles for drug purchases.

For example, my previous insurer Cigna paid for generic Crestor (rosuvastatin calcium) 10 mg tablets as a "preventative treatment" which it could do under IRS rules, hence I paid nothing for the drug. But when I was switched to Aetna (which is owned by CVS Health, who also owns the PBM known as Caremark), I was charged $33.84 for a 90-day supply of that same drug. The drug, incidentally, is made in India and costs CVS Health pennies on the dollar. I believed I was being taken advantage of by Caremark, so I asked the PBM to no longer auto-refill that mail order prescription. I then shopped for a better price and found I could buy it and initially found it by using the OptumPerks coupon-generating website/app (I bought it from rival United Healthcare's Optum Store, which is run by its PBM OptumRx for just $15.00 for a 90-day supply). Optum now mails it to my home just as Caremark once did, only I save 56%. By the way, a conversation with Caremark revealed that Aetna was only crediting me just $4.50 applied toward my deductible, even while Caremark charged me $33.84 for that drug. I would have to refill the drug for like 2 years to save what I did simply by bypassing my own insurance once.

As noted, it also works for insulin. But the lowest price for that seems to be with Lilly's Lilly Insulin Value Program which is a manufacturer coupon enabling patients to buy Lilly Insulin Lispro for a cost of $35/vial. I actually PREFER lispro over aspart (my insurance company's "preferred" insulin brand is from Novo Nordisk), but at just $35/vial, I could actually just skip whatever brand Caremark says I should use, but my co-pays have been pretty low (my last refill was $17.42 for 3 vials, which is an average cost of $5.81/vial) so I do use Fiasp instead. I simply avoid Novolog (aspart) completely. I still prefer lispro over any Novo Nordisk insulin variety, but prefer Fiasp's time-activity profile slightly over Novolog's which I derisively call "slow-mo log" because it was only marginally faster than Regular for me.

I still like the true generic test strips which work in the old OneTouch Ultra meters I blogged about HERE. I have found those to be a very cost-effective alternative to overpriced test strips. 

But OneTouch has since stopped making the old Ultra meters, so it may not be a viable alternative if you don't have a trunk full of old meters. In that case, you CAN use a meter from Roche's Accu-Chek. There are coupons enabling you to buy those at a price of about $12.25 for 50 test strips with a SingleCare coupon.

That works out to a cost of $0.24/strip. By comparison, the generic OneTouch Ultra test strips from Unistrip Technologies, Inc. http://www.unistrip-tech.com/ and GenUltimate! http://pharmatechsolutions.co/ work out to a cost of about $0.16/strip which is a lower price. For the record, Pharmatech Solutions appears to have shifted focus to sell its strips abroad for the time being, so its unclear if they're currently being sold in the U.S. anymore. But I lucked out: fortunately, my insurance now covers my test strips pre-deductible in accordance with the 2019 IRS re-classification as a "preventative treatment" eligible for pre-deductible coverage.

But my current insurance company Aetna/CVS Caremark was a complete pain-in-the-ass about covering the quantity of test strips I use (I use between 12-14 test strips per day). It took nearly a year before they approved my endo's appeals. Then, the clerks at CVS Pharmacy couldn't figure it out. First, they kept submitting the order and being denied. Eventually, they figured out that the quantity I was approved for was not evenly divisible by 100, which meant they had to use an NDC for packages of 50 test strips in order to fill my script. That was a hassle I eventually resolved. But it proved to me what a pain-in-the-ass Caremark actually is as a PBM. The company's sole concern is about how to keep the cash flowing into CVS Health's corporate coffers. Patient care is merely the fraudulent "front" they use to get there.

BTW, CVS Health (in spite of not operating a Caremark-powered coupon-generating website/app as its big rivals do) does operate a less generous coupon-generating website for some insulin, specifically Novo Nordisk rDNA biosynthetic "human" insulin. It calls the coupon-generating website ReducedRx https://www.reducedrx.com/ and offers some discounts for cash-payers on certain older Novo Nordisk rDNA biosynthetic "human" insulin varieties. If you use one of those insulin varieties, this site could save you some money. I haven't compared their prices to Lilly Humulin insulin varieties.

It doesn't matter too much now. By this summer, I could end up being covered by a completely different healthcare plan. Every few years, the contract goes up for bid and usually it means a switch to a new carrier. A previous employer finally worked around that by using a Professional Employer Organization (or "PEO") which meant a reliable contract with premiums which did not double when the contract expired. But not every organization has figured out how to do that, hence they put their insurance benefits up for bid and use a broker to solicit bids from insurance companies. Usually it means switching to a different insurance company. 

Over the past decade, I've been covered by virtually all of them: Anthem, United Healthcare, EmblemHealth of New York, Cigna, and Aetna. I could go on an on about what each company does differently, and how I navigated that, but the point is that patients must look out for their own costs. Insurance and PBM's are NOT looking out for you; they are more concerned with lining their own pockets so patients must navigate this dysfunctional system on their own.

These methods may help.

On the bright side, I am optimistic that the Civica Rx biosimilar insulin deal on insulin glargine, lispro and aspart. They have a website at https://www.civicainsulin.org/ (I blogged about the Civica Rx announcement HERE) which has potential to truly disrupt the dysfunctional status quo. In fact, the New England Journal of Medicine covered that in this month's issue. See their coverage at https://www.nejm.org/doi/full/10.1056/NEJMp2203001 (note: if you're not a NEJM subscriber, as your doctor for a copy of the article; they likely subscribe or can get the article text for you if you asked them nicely).