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Diabetes is a costly chronic condition;successful disease management requires ongoing access to diabetes-specific supplies and services, as well as insulin and other medications. As patient costs rise, patient adherence to care regimens declines and the risk of expensive and life-threatening complications increases. We applaud Congress for capping out-of-pocket (OOP) insulin costs at $35 per monthly prescription among Medicare Part D enrollees, but more must be done. It is time for Congress to help all Americans with diabetes by setting a national standard across all government and commercial plans for low, predictable cost-sharing on insulin.
• For commercial insurance, cap OOP insulin costs at the lesser of $35 or a low percent of net cost for a 30-day supply. For uninsured patients, implement an appropriate mechanism to cover costs that exceed $35 for a 30-day supply of insulin.
• Require pharmacy benefit managers (PBMs) to pass through 100 percent of manufacturer rebates and discounts for insulin to insurance plans and to patients.
• Ensure access to generic and biosimilar drugs through equitable formulary inclusion.
• Limits monthly cost-sharing for at least one insulin type (rapid-acting, short-acting, intermediate- acting, or long-acting) and dosage form (vial or pen) to $35 or 25 percent of the list price, whichever is lower.
• Requires PBMs to pass through 100 percent of insulin rebates and discounts from manufacturers to insurance plans. (Note: DPAC supports requiring these discounts to be passed through to patients, not just to insurance plans.)
• Promotes competition from generic and biosimilar drugs by easing the approval process and formulary access for biosimilar drugs in Medicare Part D.
• Largely limits insurers from imposing prior authorization and medical management on insulin products and seeks to speed up new competition to further reduce costs.
• Requires private group or individual plans to cover one of each insulin dosage form (vial or pen) and insulin type (rapid-acting, short-acting, intermediate-acting, or long-acting) for n
more than $35 per month.
• Requires the Secretary of Health and Human Services to establish a program to reimburse qualifying entities for covering any costs that exceed $35 for providing a 30-day supply of insulin to uninsured patients.
Diabetes care is preventive and should be covered accordingly in all health plans. Preventive care benefits more just the individual beneficiary; it has substantially positive economic outcomes for our country, ensuring that as Americans with diabetes age, their health outcomes are better and require less support from Medicare and other federal programs.
Waiving deductibles and cost-sharing for insulin and other diabetes management essentials is the most effective and equitable health benefit plan structure for Americans with diabetes or pre-diabetes. When waived cost-sharing is not possible, patient costs should be kept low and predictable throughout the plan year.
DPAC supports insulin caps at the lesser of $35 or a low percent of net cost so plan members directly benefit from any insulin rebates and discounts negotiated on their behalf, just as they benefit from negotiated plan rates for office visits, lab tests, and other care. Low, capped cost-sharing helps keep insulin costs level throughout the plan year, making it easier for families to budget and use insulin as prescribed rather than risking significant complications or even death by rationing their insulin.
Twenty-five states1 have already passed insulin cost-sharing cap legislation. It is time to protect all Americans by putting in place a national standard across all government and commercial plans, including Affordable Care Act (ACA) and Employee Retirement Income Security Act (ERISA) plans.
Further, Congress should improve insulin affordability by capping cost-sharing at the lesser of $35 or 25 percent of the negotiated price for all FDA-approved insulins covered by a patient’s health plan, which includes all insulin prescriptions in the quantity prescribed. With retail prices now as low as $100 or even $50 for authorized generic and interchangeable biologic insulins, patient costs will be even less than $35 if health plans cover these lower list price alternatives rather than their high list price reference products that carry rebates of 80 percent or more.
While a national insulin cost-sharing cap does not solve systemic problems driving up prescription drug prices, it does ease the current financial harm to people with diabetes and their families until policy makers are willing and able to comprehensively address perverse financial incentives in the current rebate-based system that inflate prices for insulin and other prescription drugs.
DPAC is an alliance of people with diabetes, caregivers, patient advocates, health professionals, diabetes organizations and companies working together to support public policy initiatives on behalf of the more than 37 million Americans with diabetes. As an organization co-founded and run by people with diabetes, DPAC seeks to ensure the safety, quality, and affordability of medications, devices, and services, and aims to improve the health of all Americans living with diabetes.
