Since it's January (a new year), and about half of all Americans with employer-sponsored healthcare insurance plans have some deductibles to satisfy before their healthcare insurance really kicks-in to cover much of anything, and also because deductibles reset on January 1, I thought perhaps this might be a good time to write a little about my own experience with high-deductible insurance plans and discoveries of some intelligent work-arounds, some of which I've used successfully myself.
Who knows? You might (as I did) find you actually like using a particular brand or variety of insulin which is not "preferred" by your insurance's PBM, or maybe you find a competing CGM brand has some features which you like better. Or maybe you like saving money, or are forced to do so.
Read on for more!
It may seem counterintuitive (after all, health insurance is supposed to help pay for our medical care), but the data is clear: it is frequently wiser for many patients to bypass their own insurance to purchase medicines and medical devices used in the treatment of autoimmune Type 1 diabetes (especially true if you have deductibles to satisfy before your pharmacy benefits become effective; disregard the myth [and it IS a myth] that paying artificially-inflated prescription prices contributes meaningfully toward satisfying deductibles, because your insurance is only applying their deeply-discounted PBM-"negotiated" prescription prices towards your deductible, not the much higher price you'll actually pay at the pharmacy checkout counter).
This post provides notes on insulin, glucagon, and Continuous Glucose Monitor (CGM) sensors. Note: Type 2 diabetes is a disease with a different etiology from Type 1 diabetes, and there are vastly more prescriptions approved to treat that particular disease (Type 1s have a choice between insulin or death), and that also means that many drugs used to treat Type 2 diabetes still remain protected by patents. I make no effort to address those here; that is beyond the scope of this post (but I welcome others to use this as a model for your own blog posts).
The Facts:
Peer-reviewed academic research data shows a few undeniable truths.
The main reason Americans pay more for prescriptions is not because the greedy pharmaceutical industry prices their drugs vastly higher in the U.S. while selling them for a lot less in other countries (the reason is because their realized "net" prices after discounts are about the same in the U.S. as they are in Europe and elsewhere). University of Southern California (USC) researchers found that (see https://healthpolicy.usc.edu/article/more-than-half-of-insulin-expenditures-going-to-middlemen-new-usc-schaeffer-study-finds/ for more) between 2014-2018, Pharmacy Benefit Managers (PBMs) were taking home more than half — about 53% — of the net proceeds from the sale of insulin, a percentage which had increased from just 30% in 2014. Meanwhile, at the same time, the share going to insulin manufacturers had simultaneously fallen by one-third. In a different USC study (see more at https://mann.usc.edu/news/in-the-news-paying-cash-for-prescriptions-could-save-you-money-23-of-the-time-usc-analysis-shows/), researchers also found that U.S. pharmacy customers would be better off paying cash nearly a quarter (23%) of the time, most often on generic and biosimilar drugs (although not limited exclusively to those).
We now know the reason Americans pay more for prescriptions is because the massive cash discounts called "rebates" (which totalled more than a quarter of a trillion dollars in 2022, estimated at $236 billion at the time) which is being paid by drug, biotech and medical device companies to PBMs for formulary placement are instead being misdirected rather than for lowering patient prices. That is a complicated way of saying that intermediaries like PBMs (and to a slightly lesser extent drug wholesalers), are taking money which really should be going toward reducing the prices U.S. patients pay.
The PBM industry euphemistically calls those "misaligned incentives", but it really should be called theft. As of June 7, 2022, the U.S. Federal Trade Commission (FTC) was studying PBM "business practices" with a comprehensive 6(b) study (FTC Matter No. P221200), (see https://www.ftc.gov/news-events/news/press-releases/2022/06/ftc-launches-inquiry-prescription-drug-middlemen-industry for the bipartisan study announcement). Upon that FTC study's conclusion, it may result in litigation against the PBMs and their insurance company parents (Aetna/CVS Health/Caremark being a slight role-reversal). Until the FTC acts on PBMs, here are some practical tips to navigate the shark-filled waters of buying prescriptions for Type 1 diabetes in the U.S.
The PBM industry euphemistically calls those "misaligned incentives", but it really should be called theft. As of June 7, 2022, the U.S. Federal Trade Commission (FTC) was studying PBM "business practices" with a comprehensive 6(b) study (FTC Matter No. P221200), (see https://www.ftc.gov/news-events/news/press-releases/2022/06/ftc-launches-inquiry-prescription-drug-middlemen-industry for the bipartisan study announcement). Upon that FTC study's conclusion, it may result in litigation against the PBMs and their insurance company parents (Aetna/CVS Health/Caremark being a slight role-reversal). Until the FTC acts on PBMs, here are some practical tips to navigate the shark-filled waters of buying prescriptions for Type 1 diabetes in the U.S.
Drug, biotech companies and medical device manufacturers are aware that the rebate-contracting sales model promoted by the largest PBMs often means patients pay far more money than they should be for their products, but they felt powerless to abandon the PBM rebate-contracting model because of veiled threats they received from the big PBMs about "formulary exclusions" for all of their drugs (not limited to insulin). A good overview of what happened in the case of insulin can be read HERE.
But a number of manufacturers (including CGM-makers) now offer discount coupons enabling patients to buy their products (as long as patients are NOT submitting the same purchases as claims to commercial health insurance or government healthcare plans; check the fine-print for details). In the past, manufacturer discount coupons were limited in size, not available to all, were difficult to use, and some were only available for a limited time. As of 2024, for Type 1 diabetes prescriptions at least, manufacturer discount coupons are no longer limited-time offers (they are part of the manufacturers ongoing "marketing" expenses), available to most anyone and can substantially reduce the amount patients are charged.
But a number of manufacturers (including CGM-makers) now offer discount coupons enabling patients to buy their products (as long as patients are NOT submitting the same purchases as claims to commercial health insurance or government healthcare plans; check the fine-print for details). In the past, manufacturer discount coupons were limited in size, not available to all, were difficult to use, and some were only available for a limited time. As of 2024, for Type 1 diabetes prescriptions at least, manufacturer discount coupons are no longer limited-time offers (they are part of the manufacturers ongoing "marketing" expenses), available to most anyone and can substantially reduce the amount patients are charged.
The following contains a brief description of different manufacturer discount coupons along with links of where those coupons can be found.
Dexcom Manufacturer Coupon:
Download a Dexcom manufacturer coupon to save $200 per 30-day supply of sensors (and an additional $200 on each 3-month transmitter on the G6 model). Manufacturer coupons work for both those insured with high-deductibles to satisfy as well as cash-payers. Generally, to evaluate whether a coupon saves you money, compute your daily cost of wearing a CGM sensor in order to determine if it might be less costly to use a manufacturer coupon rather than the pharmacy benefit of your insurance. While competing CGM sensor brands cost about the same, your cost must be evaluated by how many days you can actually wear each CGM sensor. Dexcom coupons can be used without insurance. However, some patients find that Dexcom's Automated Insulin Delivery (AID) partnerships with insulin pump manufacturers may still make Dexcom their preferred choice for them in spite of its slightly higher cost.
Abbott Freestyle Libre eSavings Voucher:
If you're commercially insured and asked to pay more than $75 for two Freestyle Libre 3 sensors, call Abbott customer care at 1-855-632-8658 (M-F from 8-8 ET) to ask for an eSavings voucher to be emailed to you. Abbott eSavings vouchers expire at the end of each calendar year, but they can be renewed by telephone at the beginning of each new year. Note that some Libre CGM models feature 14-day wear-time. Generally, less frequent sensor changes save patients money unless your insurance assumes some portion of the cost, but do the math to find out. To do so, take your monthly CGM cost and divide that amount by the number of sensors in each refill (generally, 3 for Dexcom or 2 for Libre). Then, divide that figure by the number of days each sensor can be worn. My Aetna/CVS Caremark plan covers 37% of the cost of Dexcom sensors pre-deductible, yet I still found the Libre 3 model to be less costly with the Abbott eSavings voucher due to the longer wear-time of the sensors if I if I buy them at Costco Pharmacy. Abbott Freestyle Libre coupons can be used without insurance. Although Libre 3 currently has no pump partnerships in the U.S. (it has some in Europe), the Libre system nevertheless has several advantages over Dexcom G6/G7 including its lower cost due to its longer wear-time, as well as updating new readings every minute compared to Dexcom reading updates every 5 minutes. That translates into 1440 new CGM readings each day with Libre 3 compared to only 288 new CGM readings with Dexcom.
Lilly Insulin Value Program:
Lilly insulins are available for $35/month regardless of whether a patient has commercial insurance or no insurance. Lilly's unbranded insulin (Lilly Insulin Lispro Injection 100 U/mL) tends to be the least-costly option for cash-payers (including insured patients with deductibles to satisfy before pharmacy coverage kicks in) instead of branded Humalog (even though it is the exact same insulin) when a manufacturer coupon is submitted to the pharmacy with the patient payment by bypassing their healthcare insurance, hence Lilly Insulin Value Program coupons may be used without insurance.
Sanofi ValYou Insulins Savings Program:
My readers may recall that in 2022, Sanofi very quietly introduced an unbranded version of Lantus via the company's Winthrop US business unit over two years after rivals Lilly and Novo Nordisk did the same (I blogged about it HERE), and I suspect the reason was because Lantus was dumped from Express Scripts' formularies in favor of the interchangeable biosimilar known as Biocon's Semglee in 2022. Regardless, the Sanofi Insulins ValYou savings program is not insurance and is not valid for prescriptions covered by or submitted for reimbursement, in whole or in part, under commercial/private insurance, Medicare, Medicaid, VA, DOD, TRICARE, similar federal or state programs, including any state pharmaceutical programs. Eligible cash-paying patients will pay $35 per 30-day supply with a ValYou savings coupon presented to a pharmacy when filling your prescriptions. To pay $35 per 30-day supply, patients must fill all Sanofi insulin prescriptions at the same time, together each month and using the ValYou savings coupon at the time of payment. The Sanofi Insulins ValYou savings program applies to the cost of medication. Sanofi reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms of use at any time without notice. Sanofi Insulins ValYou savings coupons may be used without insurance.
NovoCare Manufacturer Discount Coupons:
Novo Nordisk offers unbranded biologics (also sometimes referred to as "authorized biologics" or "authorized generics") which are identical to the branded NDC's of insulins made by the same organization, but are sold under the generic drug names as Novo Nordisk-branded analogue insulins which are sold at a significantly reduced list price in the U.S. from Novo Nordisk Pharma, Inc. (NNPI) unit, which is a Novo Nordisk A/S company. The company copied exactly what Lilly did recognizing it was a good idea given its own contribution to the PBM rebate-driven affordability problem it was perpetuating. Insulin Degludec Injection 100 U/mL, 200 U/mL, and Insulin Aspart Injection 100 U/mL are among the versions of branded insulins sold as unbranded products designed to bypass list price inflation caused by the rebate-contracting model of the large Pharmacy Benefit Managers in the U.S. With availability of unbranded biologic versions of its insulin analogues, Novo Nordisk is providing this affordability option as part of its broader community commitment. NovoCare coupons may be used without insurance.
Xeris Gvoke Hypopen Manufacturer Coupon:
Eligible commercially insured patients may pay as little as $25 with a manufacturer copay card. Note: the Gvoke manufacturer copay card does NOT currently apply to cash-payers, it must be used WITH health insurance (hence, they call it a "copay card" not a coupon).
Zealand Pharma (via Novo Nordisk) Zegalogue Savings Offer:
If you have commercial insurance, such as insurance you receive through an employer, depending on your insurance coverage and out-of-pocket responsibility, you may pay $35 or $99 for each one-pack prescription for up to 48 months from date of Savings Offer activation. Call 1-833-992-3299 to request a Zegalogue Savings Offer from NovoCare. NovoCare coupons may be used without insurance.
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