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Onto The Street Blog

The Diabetes Drug Curtain

"The important thing is not to stop questioning. Curiosity has its own reason for existing."
                                                                                     —Albert Einstein


Special thanks to diabetes patient advocate and diabetes drug cost expert Scott Strumello for graciously sharing his insights and notes below as a follow up to his conversation on The Dave and Amber podcast.

Introducing Diabetes Drug Key Players
The next time you find your wallet weeping in the pharmacy checkout line, it may be that Pharmacy Benefit Managers or PBM’s are the ones that should be offering you a tissue. These SuperGiants, including well known CVS Caremark and Express Scripts (to name just a few) are the closed door negotiators largely determining the cost of our diabetes prescriptions. PBM’s add another level of sorcery to the already mystifying land of drug manufacturers, insurance, consumers and pharmacy. We were fortunate to visit with Scott Strumello, diabetes patient advocate and drug cost transparency expert, on the Dave and Amber Show and share his notes below in efforts to help us all see what’s behind the diabetes drug curtain. In my efforts to recap Scott's amazing details below, I've included my own lay person's  "Two Point Take-Away" as a  debrief to each section. 


Are Pharmacy Benefit Managers A Benefit

The key work-around on prescription drug prices for patients, is that Pharmacy Benefit Managers (PBM's) are now cannibalizing their own plan sponsored clients with coupon-generating websites and apps. These sites/apps significantly
reduce patient out-of-pocket costs on many diabetes drugs. Most of the big coupon-generating websites/apps have one or more PBM's as the puppet-master behind them. 

Covered patients may be told by their employers that they must satisfy deductibles before their prescription costs are covered. But patients may choose to ignore the myth which persists, that Rx drug purchases contribute meaningfully towards deductible satisfaction (they usually do no such thing). In reality, insurers typically only credit covered individuals for their own PBM-negotiated, deeply-discounted drug prices, not the artificially-inflated retail cash prices patients are charged at the pharmacy checkout.

Two Point Take Away-
The same people that are offering you a savings coupon, may also be the ones responsible for the high cost starting point of our medications, and the cash you're shelling out at the pharmacy for "un-benefitted" prescriptions is not necessarily being applied to that often hefty deductible. Weep. Another tissue please. 

Use The Coupons With The Understanding They Are Not The Solution
It seems odd that a PBM like Cigna's Express Scripts is now willing to cannibalize its own clients with InsideRx coupons, yet they are doing just that. Ditto for United Healthcare's OptumRx via OptumPerks, or WellDyne's WellCardRx. Coupon-generating websites/apps are really
a crack in the dam of PBM monopolization of prescription drug discounts. Patients can and should use available coupons to their financial benefit when possible. 

Before we get to the coupon crack in the dam of PBM discounts on prescription drugs, it's critical to acknowledge that there's a special exception for still-new, still patent-protected prescription drugs. The "New Drug Rule" basically requires coupons to come direct-from-manufacturer (the parties who make the drug) because PBM-powered discount coupons are not yet readily available. Without coupons, very few of us can afford the sticker price that comes with “new” or novel drug. The rules for manufacturer coupons are unique to each drug, many exemptions and exclusions exist, as there is no mandated uniformity.
You can find an extensive list of manufacturer coupons on our
Patient Assistance Page.

Two Point Take Away-
We should use the available cost savings programs to our benefit knowing they are a product of the same people who are making is necessary to use a coupon. Whaaaaaat...???? And, good luck finding a coupon for any new or novel diabetes drug, they puppet masters have not yet had time to conjure up a nicely packaged "savings" circus (...yet). Hit the drug manufacturer's websites instead. Check this comprehensive list here. 

Scott’s Comprehensive Diabetes Drug Website Savings Round Up
SingleCare https://www.singlecare.com/ is unique among coupon-generating websites/apps in
that it contracts directly with pharmacy chains to negotiate discounted cash prices rather than using a PBM or combo of PBM's. It's managed by Boston-based RxSense. Because its model is pharmacy-driven, discounts tend to be better on non-rebated drugs such as generics and some medical devices. SingleCare's discounts which are given to the consumers may not be quite as deep as PBM-powered coupon generating websites/apps on a number of drugs (particularly brand-name drugs).

Still, on less-heavily rebated prescription drugs and devices which have more room for price variability, including on CGM sensors (including Dexcom and Abbott Freestyle Libre) and on Roche's Accu-Chek glucose testing supplies, the discounts may be useful. The discounts are limited, but are certainly better than paying artificially-inflated cash retail prices. SingleCare also offers access to discounts on certain vaccinations.

MedImpact Healthcare Systems is officially independent, yet is de facto controlled by its largest client: the huge HMO known as Kaiser Permanente. MedImpact works with many different coupon-generating websites/apps. MedImpact "powers" several coupon-generating websites/apps. Among them are ScriptSave WellRx https://www.wellrx.com/ and America's Pharmacy https://www.americaspharmacy.com/ both of which describe themselves as "members of the MedImpact family of companies". BlinkHealth https://www.blinkhealth.com/ is officially independent, but also uses MedImpact as its PBM. MedImpact also happens to be one of GoodRx's multiple PBM's.

GoodRx https://www.goodrx.com/ is the 800-lb. gorilla among coupon-generating websites/apps, and uses several PBM's, including MedImpact, Cigna's Express Scripts, United Healthcare's OptumRx, and Navitus (which is a PBM owned by the nonprofit hospital chain SSM Health & Costco). Last April, GoodRx also acquired a rival coupon website/app known as RxSaver by RetailMeNot https://www.rxsaver.com/ from Vericast (which previously owned/ran RetailMeNot).

The main reason GoodRx cannot always offer the lowest prices is because it only offers access to a single formulary offered by each PBM, and most PBM's offer multiple drug formularies hence it misses lower (often generic) prices on the excluded formularies. For example, the Express Scripts' biggest formulary (which reportedly covers more than 28 million lives) is a high-price/high-rebate formulary known as the National Preferred Formulary [NPF]. That formulary tends to "prefer" more expensive brand-name drugs which pay big cash rebates to the PBM. But the Express Scripts' National Preferred Flex Formulary is a different formulary which GoodRx does not have access to and that tends to favor drugs with lower list prices (notably generics) over the high-list/high-rebate versions of drugs. Those lower drug prices are all notably excluded from GoodRx. That means individuals using GoodRx are missing potentially lower prices (especially on generics) found elsewhere. But I have actually found InsideRx does offer access to the Express Scripts' National Preferred Flex Formulary and its prices are frequently lower than GoodRx's prices are, especially when one uses the Express Scripts Cash-Pay Mail Order Pharmacy due to its self-preferencing its own mail-order pharmacy.

As noted, Cigna's Evernorth Express Scripts PBM operates a coupon-generating website/app called InsideRx https://insiderx.com/ and Express Scripts' mail order pharmacy often underprices rival pharmacies within its own network on generics. Express Scripts self-preferences its own mail order pharmacy with lower prices on prescriptions ordered from Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx https://www.express-scripts.com/rxdiscount/#/ compared to other pharmacies within its retail network, and its prices on many drugs are pretty competitive, especially on generic drugs.

United Healthcare's OptumRx PBM business operates OptumPerks https://perks.optum.com/ (formerly branded as SearchRx which no longer exists) and its Optum Store https://store.optum.com/. This particular site/app omits coupons for many brand-name drugs, but it comes in as the low-price leader on certain generics which Optum sells lots of, such as generic statin drugs to manage elevated LDL cholesterol.

The PBM WellDyne's WellCardRx https://wellcardrx.com/ (which also offers a mail-order pharmacy if it's more convenient, but its mail order prices are no lower than via the pharmacies within its retail network). It should be included among the coupon-generating sites/apps patients check, although it says users should confirm prices with their pharmacist. It provides a list of 5 local pharmacies based upon your zip code. Its search functionality needs some work.

Drug wholesaler McKesson offers a coupon-generating website/app called ScriptHero https://www.scripthero.com/ (powered internally through CoverMyMeds which McKesson acquired in 2017, plus SingleCare and WellRx). ScriptHero, in particular, offers the lowest prices (unless you use a manufacturer discount coupon on a generic glucagon kit [prices with a coupon from Fresnius Kabi USA costs just $5 up to a maximum monthly/annual dollar amount; some limitations apply and eligibility may be limited; visit https://kabicare.us/patient/program/hypoglycemia-low-blood-sugar/commercial-copay-support-glucagon/ for full details and to download a co-pay assistance card] on the old-school generic glucagon emergency kits which were first approved by FDA in December 2020).

CVS Caremark does NOT offer a coupon-generating website/app making it the odd man out among big PBM's, although the company does offer a seldom-acknowledged discount coupon program called ReducedRx https://www.reducedrx.com/ which offers some discounts for cash-payers on certain older Novo Nordisk rDNA biosynthetic "human" insulin varieties. If you use one of those insulin varieties, it could save you some money.


The Low Down On Generic Diabetes Drugs
Thanks to "authorized generic" versions of Humalog https://www.prnewswire.com/news-releases/lilly-to-introduce-lower-priced-insulin-300805560.html and Novolog https://www.prnewswire.com/news-releases/novo-nordisk-launching-additional-us-insulin-affordability-offerings-in-january-2020-300913167.html, prices on Lilly Insulin Lispro https://www.lillyinsulinlispro.com/ and Novo Nordisk Insulin Aspart https://www.nnpi.com/ are comparatively affordable, at least until Civica Rx introduces its own biosimilars of them, which promise to be less costly than many patients' co-pays are currently. 

You can find the Civica Rx press release "Civica to Manufacture and Distribute Affordable Insulin" at http://dlvr.it/SL0QZV  Civica plans to make biosimilars of insulin glargine, lispro and aspart (planned for 2024). They have yet to announce plans to sell a generic glucagon emergency kit. The current glucagon generics approved in 2020 are curiously overpriced at over $200, but it's still early, so as consumers, we will have to wait. 

The biosimilar maker Viatris/Biocon also offer a branded/unbranded version of insulin glargine (innovator brand-name: Lantus) called Semglee or Viatris/Biocon U-100 Insulin Glargine. The unbranded U-100 Insulin Glargine-yfgn (which FDA has classified as "interchangeable" (which enables drugstores to switch brands unless the doctor designates on the script "Dispense As Written") with the branded reference product known as U-100 Sanofi Lantus and has a reported list price of 65% less than brand-name Lantus sells for.

Fee Based Discount Programs
In general, my advice is usually to avoid paying for drug discounts via a premium offer such as GoodRx Gold, Kroger Rx Savings Club, or a pharmacy discount program such as the Walgreens Prescription Savings Club, all of which are fee based membership programs. The Walgreens program carries an annual fee of $20 per individual or $35 per family.  In my assessment, the savings of those programs seldom justify the fee you are charged (although the Walgreens program offers pretty decent prices on glargine insulin pens, it also carries a fee to get the discount). PBM-powered coupons will frequently yield comparable savings on prices for most drugs, and most of the websites/apps are now free.

Two Point Take Away-
It's going to take some Google searching, as well as some trial and error to find what's most beneficial, both cost and health wise for you and your oved ones. 

About The Author
Scott Strumello is a patient approaching his 50 year Joslin Medal for living with Type 1 diabetes. He blogs at https://blog.sstrumello.com/ but my be better known for his Twitter feed https://twitter.com/sstrumello which has occasionally been known to break news on the diabetes front before many rival sources. He is also a person who understands much more about prescription drug pricing than I ever will. Thanks Scott for clueing us in!