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Prescription Medicines:
Insulin Costs in Context
2019
2
Medical innovation has transformed the lives of diabetes
patients.
More recent advances have driven much of this transformation.
A century ago, patients were treated with animal insulins. Today, patients have access to insulins that
operate at the molecular level that more closely resemble insulin release as it naturally occurs in the body.
*NOTE: Modern insulin treatment protocol often requires long-acting insulin to provide a base level of coverage all day along with meal-time administration of insulin to modulate spikes in blood glucose.
Maintenance of stable and consistent blood sugar levels is better than ever before, helping
to avoid serious complications and reduced weight gain.
Longer-acting insulins provide coverage for over 24 hours and enable greater flexibility in
dosing and reduced risk of dangerous blood sugar drops.
Rapid-acting insulins—including an inhaled form—enable dosing directly before or even
after meals, rather than in anticipation of meals
Insulin pens offer greater convenience, including some that reduce injections for high doses
or ease use in children.
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
3
Better diabetes management saves money and improves
health outcomes.
SOURCE: American Diabetes Association
SOURCE: Jha, et al. “Greater Adherence to Diabetes Drugs is Linked to Less Hospital Use and Could Save Nearly $5 Billion Annually.” Health Affairs
Improving Medication Adherence
Among Diabetes Patients Could:
22
million
Americans live with
uncontrolled diabetes.
Save $8.3 billion for the U.S.
health care system each year
Result in 1 million less ER visits
and hospitalizations annually
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
4
Amount discounts can
lower the list price of
insulin, according to
industry analysts
Amount prices after
discounts and rebates
have fallen in the last
two years for long-
acting insulins
Net prices for long-
acting insulins are
less expensive now
than in 2010
After discounts and rebates, prices for the most commonly
used insulin classes are declining.
70% 30%
SOURCE: Bloomberg Businessweek, June 29, 2017; Bloomberg.
June 29, 2016.
SOURCES: SSR Health. “US Brand Net Pricing Growth 0.2% in 3Q17,”
December 2017. Eli Lilly, Press Release, March 2019.
SOURCE: SSR Health. “US Rx net prices fall 4.8 percent y/y in
4Q18.” March 18, 2019.
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
5
Middlemen expose insulin patients to list prices through coinsurance
or deductibles. Over the past 10 years in the commercial market:
Diabetes patients face soaring out-of-pocket costs.
Source: Kaiser Family Foundation, October 2016.
The share of patient out-of-pocket medicine
spending represented by coinsurance has grown
2x
The share of patient out-of-pocket medicine
spending represented by deductibles has grown
3x
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
6
Insurers and PBMs have a lot of leverage to hold down
medicine costs.
Negotiating power is increasingly concentrated among
fewer pharmacy benefit managers (PBMs).
Top 3
Market Share:
76%
23%
30%
23%
24%
OptumRx (UnitedHealthGroup)
CVS Health (Caremark)
Express Scripts
All Other
Insurers determine:
FORMULARY
if a medicine is covered
TIER PLACEMENT
patient cost sharing
ACCESSIBILITY
utilization management through
prior authorization or fail first
PROVIDER INCENTIVES
preferred treatment guidelines
and pathways
Source: Drug Channels Institute, March 2019.
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
7
Cost sharing for nearly 1 in 5 brand
prescriptions is based on list price
More than half of commercially insured
patients’ out-of-pocket spending for brand
medicines is based on the full list price
Negotiated savings are often not shared with patients.
44%
26%
29%
55%
Copay
Deductible
Coinsurance
Source: IQVIA. May 2018.
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
8
For a typical Part D patient with diabetes taking
five medicines, including insulin:
Sharing negotiated rebates would lower Medicare Part D
patient costs.
Out-of-pocket spending could
decrease nearly $900 a year
Premiums would only increase
$3 to $6 a month, as little as a
dime a day
SOURCES: Avalere Analysis, 2019; OACT, Milliman and Wakely Analysis, February 2019.
NOTE: Plan cost includes medical and pharmacy claims
If we don’t reform the rebate
system, diabetes patients could
pay twice what their insulin
costs to their insurer when they
are in the deductible.
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
9
Example: High-Deductible Health
Plan with a Copay
Example: High-Deductible Health
Plan with Coinsurance
Sharing negotiated rebates could save commercially insured
patients as well.
Source: Milliman Analysis, October 2017.
She would save $359 a year
Her premium would increase
less than 1%
Mary has diabetes and spends
$1,000 each year on medical and
pharmacy expenses
She would save about $800 a year
Her premium would increase
less than 1%
Kevin has diabetes and several
other health conditions and spends
$5,000 each year on medical and
pharmacy expenses
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
10
DELINK SUPPLY CHAIN PAYMENTS FROM THE LIST PRICE OF A MEDICINE
• Advance reforms that prevent PBMs and other supply chain entities from having their compensation calculated as
a percent of the list price of a medicine and instead based on a fee based on the value their services provide
FINALIZE PROPOSED RULE TO REFORM REBATE SYSTEM IN MEDICARE PART D
• Replace the current system of rebates in Part D with a system where discounts are passed directly on to patients
at the pharmacy counter
ENSURE PATIENTS WITH STATE-REGULATED INSURANCE ALSO DIRECTLY BENEFIT
FROM REBATES
• Support legislation at the state-level that would reduce patients’ out-of-pocket costs by sharing discounts and
rebates with patients at the pharmacy counter
COUNT THIRD-PARTY DISCOUNT PLANS TOWARD DEDUCTIBLES
• Change private health insurance rules to require health plans to count the cost of prescriptions purchased
through third-party programs, like Blink Health and GoodRx, toward patient maximum out-of-pocket limits
SUPPORT FIRST DOLLAR COVERAGE OF INSULIN FOR HIGH-DEDUCTIBLE HEALTH
PLAN PATIENTS
• Clarify Department of Treasury rules to make sure high-deductible health plans must provide coverage of
insulin and other chronic disease medicines prior to the deductible
Policy solutions to address insulin affordability challenges.
SUPPORT FLAT COPAYS FOR INSULIN FOR PATIENTS RECEIVING COST-SHARING
SUBSIDIES IN THE EXCHANGES
• Make regulatory changes to ensure plans put at least one of each type of insulin on a copay-only tier
Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin

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Prescription Medicines - Insulin Costs in Context

  • 2. 2 Medical innovation has transformed the lives of diabetes patients. More recent advances have driven much of this transformation. A century ago, patients were treated with animal insulins. Today, patients have access to insulins that operate at the molecular level that more closely resemble insulin release as it naturally occurs in the body. *NOTE: Modern insulin treatment protocol often requires long-acting insulin to provide a base level of coverage all day along with meal-time administration of insulin to modulate spikes in blood glucose. Maintenance of stable and consistent blood sugar levels is better than ever before, helping to avoid serious complications and reduced weight gain. Longer-acting insulins provide coverage for over 24 hours and enable greater flexibility in dosing and reduced risk of dangerous blood sugar drops. Rapid-acting insulins—including an inhaled form—enable dosing directly before or even after meals, rather than in anticipation of meals Insulin pens offer greater convenience, including some that reduce injections for high doses or ease use in children. Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 3. 3 Better diabetes management saves money and improves health outcomes. SOURCE: American Diabetes Association SOURCE: Jha, et al. “Greater Adherence to Diabetes Drugs is Linked to Less Hospital Use and Could Save Nearly $5 Billion Annually.” Health Affairs Improving Medication Adherence Among Diabetes Patients Could: 22 million Americans live with uncontrolled diabetes. Save $8.3 billion for the U.S. health care system each year Result in 1 million less ER visits and hospitalizations annually Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 4. 4 Amount discounts can lower the list price of insulin, according to industry analysts Amount prices after discounts and rebates have fallen in the last two years for long- acting insulins Net prices for long- acting insulins are less expensive now than in 2010 After discounts and rebates, prices for the most commonly used insulin classes are declining. 70% 30% SOURCE: Bloomberg Businessweek, June 29, 2017; Bloomberg. June 29, 2016. SOURCES: SSR Health. “US Brand Net Pricing Growth 0.2% in 3Q17,” December 2017. Eli Lilly, Press Release, March 2019. SOURCE: SSR Health. “US Rx net prices fall 4.8 percent y/y in 4Q18.” March 18, 2019. Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 5. 5 Middlemen expose insulin patients to list prices through coinsurance or deductibles. Over the past 10 years in the commercial market: Diabetes patients face soaring out-of-pocket costs. Source: Kaiser Family Foundation, October 2016. The share of patient out-of-pocket medicine spending represented by coinsurance has grown 2x The share of patient out-of-pocket medicine spending represented by deductibles has grown 3x Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 6. 6 Insurers and PBMs have a lot of leverage to hold down medicine costs. Negotiating power is increasingly concentrated among fewer pharmacy benefit managers (PBMs). Top 3 Market Share: 76% 23% 30% 23% 24% OptumRx (UnitedHealthGroup) CVS Health (Caremark) Express Scripts All Other Insurers determine: FORMULARY if a medicine is covered TIER PLACEMENT patient cost sharing ACCESSIBILITY utilization management through prior authorization or fail first PROVIDER INCENTIVES preferred treatment guidelines and pathways Source: Drug Channels Institute, March 2019. Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 7. 7 Cost sharing for nearly 1 in 5 brand prescriptions is based on list price More than half of commercially insured patients’ out-of-pocket spending for brand medicines is based on the full list price Negotiated savings are often not shared with patients. 44% 26% 29% 55% Copay Deductible Coinsurance Source: IQVIA. May 2018. Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 8. 8 For a typical Part D patient with diabetes taking five medicines, including insulin: Sharing negotiated rebates would lower Medicare Part D patient costs. Out-of-pocket spending could decrease nearly $900 a year Premiums would only increase $3 to $6 a month, as little as a dime a day SOURCES: Avalere Analysis, 2019; OACT, Milliman and Wakely Analysis, February 2019. NOTE: Plan cost includes medical and pharmacy claims If we don’t reform the rebate system, diabetes patients could pay twice what their insulin costs to their insurer when they are in the deductible. Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 9. 9 Example: High-Deductible Health Plan with a Copay Example: High-Deductible Health Plan with Coinsurance Sharing negotiated rebates could save commercially insured patients as well. Source: Milliman Analysis, October 2017. She would save $359 a year Her premium would increase less than 1% Mary has diabetes and spends $1,000 each year on medical and pharmacy expenses She would save about $800 a year Her premium would increase less than 1% Kevin has diabetes and several other health conditions and spends $5,000 each year on medical and pharmacy expenses Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin
  • 10. 10 DELINK SUPPLY CHAIN PAYMENTS FROM THE LIST PRICE OF A MEDICINE • Advance reforms that prevent PBMs and other supply chain entities from having their compensation calculated as a percent of the list price of a medicine and instead based on a fee based on the value their services provide FINALIZE PROPOSED RULE TO REFORM REBATE SYSTEM IN MEDICARE PART D • Replace the current system of rebates in Part D with a system where discounts are passed directly on to patients at the pharmacy counter ENSURE PATIENTS WITH STATE-REGULATED INSURANCE ALSO DIRECTLY BENEFIT FROM REBATES • Support legislation at the state-level that would reduce patients’ out-of-pocket costs by sharing discounts and rebates with patients at the pharmacy counter COUNT THIRD-PARTY DISCOUNT PLANS TOWARD DEDUCTIBLES • Change private health insurance rules to require health plans to count the cost of prescriptions purchased through third-party programs, like Blink Health and GoodRx, toward patient maximum out-of-pocket limits SUPPORT FIRST DOLLAR COVERAGE OF INSULIN FOR HIGH-DEDUCTIBLE HEALTH PLAN PATIENTS • Clarify Department of Treasury rules to make sure high-deductible health plans must provide coverage of insulin and other chronic disease medicines prior to the deductible Policy solutions to address insulin affordability challenges. SUPPORT FLAT COPAYS FOR INSULIN FOR PATIENTS RECEIVING COST-SHARING SUBSIDIES IN THE EXCHANGES • Make regulatory changes to ensure plans put at least one of each type of insulin on a copay-only tier Prescription Medicines: Insulin Costs in Context www.phrma.org/insulin