Copays, Caps and Cost Savings With Diabetes?

Alicia: UnLeashed!

A look at recent “apparent” efforts to reduce the cost of living with diabetes.

Anyone living with diabetes knows that it is expensive to stay healthy! From pump, injection and monitoring supplies, to medical appointment copays, to insulin and other drug costs, the economic toll of diabetes is a life threatening complication all its own!

A survey from the T1International in 2016 showed that the average American household with ONE person with type 1 diabetes spent over 10 percent of their monthly income on supplies and medications ALONE. This does not include the cost of insurance premiums, doctors visits or other considerations of life with Type 1.

This financial burden has sparked a backlash, not only from the diabetes community, but from the American public at large. Public news stories of people rationing insulin, with fatal results, abound. This outcry has lead to intense public and legislative scrutiny of how drug pricing is determined and regulated (at this point it is almost entirely unregulated). We all know that change at the national level is slow in coming, but we are starting to see some changes.

Following scrutiny and increased public concern raised by a Senate Finance Committee hearing in February, in March Lilly announced the release of a half cost version of Humalog to the market. This reduces the cash list price of Humalog, however, this does not impact costs of insurance copays, and this insulin is not going to be contracted with insurance company formularies. Essentially this helps a small percentage of insulin users who have no insurance coverage at all, but still at exorbitant pricing. Lilly will see a very minimal impact on their sale of Humalog to insured persons beyond meeting their initial medication deductible annually. This appears to be a very minor nod to demands for reducing insulin costs to the public to ease public opinion.

Following the Lilly announcement and in a clear attempt to stave off the ire of further House congressional hearings in April where the big three insulin producers (Lilly, Sanofi and Novonordisk) were harangued by committee members, Sanofi announced the expansion of its copay reduction program. Under this program insulin users would be capped at a $99 per month copay per Sanofi brand insulin. It is important to note that this copay cap would not currently apply to medicare or medicaid participants due to regulation of pricing the institutions, it remains to be seen how this will be handled by policy makers in the coming months. This program was to take effect in June 2019.

Both of these announcements came in a chorus with Cigna and Express Scripts announcing that they would be limiting copays of insulin users to $25 per month through their Patient Assurance Program. This program would be available to “participating non government” plans with copays greater than $25. While the plans state that this will be accomplished by moving insulin to lower tiers on their formulary. It remains to be seen whether this means that deductibles will apply before price reductions are offered. It is also suspected that this reduction will simply be padded into higher insurance rates across the board so insurers are not losing any money here either. In fact, they are demonstrating that they have had the ability and power to reduce insulin costs to consumers all along and simply waited until they were under fire to do so.

Finally came an announcement from Colorado state’s legislature in late May that they would be regulating insulin pricing to a cap of $100 per month for residents regardless of insurance provider or lack there of.   The law puts the burden on Insurance companies to absorb any financial burden in this measure. However it is again, rather obvious that insurers will likely simply pass this burden along to consumers in the form of higher plan premiums and higher deductibles.

On one side there is cause for celebration. Life with diabetes is a series of tiny triumphs that must be recognized and relished to provide the energy to persevere. However, it is also a life of constant vigilance. And so, it remains to be seen whether these cost saving measures will truly change the financial standing of people with diabetes, or whether it will simply be a diversionary tactic to make big pharma appear conciliatory while leaching our bank accounts in a less visible but no less painful way.