Patient Access and Insulin: Market Forces, Innovative PBM Programs Lowering Costs for Patients

The insulin market today is not the market of five years ago. The insulin market of the 2010s was defined by just three drug companies and their brand name products. The lack of competitors meant skyrocketing list prices, increasing once or even twice a year. But gradually things have begun to change.

Out-of-pocket costs for insulins are decreasing. A Department of Health and Human Services (HHS) study released in December 2022 found that people with diabetes who were enrolled in Medicare or had private insurance in 2019 paid an average of around $37 a month. A few years later, demonstrating the improving (lower cost) insulin market, IQVIA found that the average final out-of-pocket costs on insulin for all patients was $21.19 in 2022. Commercially insured patients paid under $35 out-of-pocket for insulin 80% of the time in 2022.

Insulin biosimilars Basaglar and Semglee represent an important step forward in biosimilar competition and lower insulin costs. Annual list price increases on insulins have, for the most part, stopped, while net prices - paid by employers and health plans - continue to fall. That means lower insulin costs for patients as evidenced by a recent IQVIA report found that "Across all patients, benefit design changes combined with the availability of biosimilars are contributing to falling insulin costs."

More biosimilars coming to market allows PBMs to more effectively leverage competition to reduce drug costs for health plan sponsors and patients.

Pharmacy benefit companies have introduced innovative programs to continue to make insulin even more affordable for more patients. One pharmacy benefit company and health plan introduced an initiative to apply manufacturer patient assistance programs in a novel way, which lowered the monthly out-of-pocket costs for insulin by 40 percent or more. Under the program, out-of-pocket costs are $25 for a 30-month supply of insulin for eligible health plan enrollees. Another PBM announced it could provide access to diabetes drugs, including insulin, at no out-of-pocket cost to eligible health plan enrollees, and save on medical expenses for the health plan. And another company announced the elimination of out-of-pocket costs in standard fully insured group plans for certain preferred prescription drugs, including insulin.

Last year, drug companies reacted to the public's desire for lower insulin prices by announcing reduced list prices, underscoring their ability to use their discretion and pricing power to lower the prices of the drugs that they make and sell, regardless of rebates or any other component. Despite that welcome price cut and significant progress through market changes, drug companies actively oppose legislation designed to reform patent schemes that keep prices high. This is never truer than with insulins: With sufficient competition, PBMs negotiate lower net prices on insulins from drug companies, securing savings for employers, patients, and taxpayers.

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PCMA is the national association representing America's pharmacy benefit companies. Pharmacy benefit companies are working every day to secure savings, enable better health outcomes, and support access to quality prescription drug coverage for more than 275 million patients.

Learn more at www.pcmanet.org