The numbers are in: U.S. spending on diabetes drugs increased from $10 billion to $22 billion per year between 2002 and 2012, according to a recent study. And most of that cost was due to skyrocketing prices for one diabetes medication: insulin. Take, for example, Lantus, one of the most popular insulins on the market. The price of a 10-milliliter vial has shot up from under $40 in 2001 to around $275 today.
And these costs are hitting more people every year. About 30 million people in the U.S. have diabetes – up from 10 million 20 years ago – with another 89 million experiencing prediabetes. One study estimates that up to one-third of Americans could have diabetes by 2050. With so many people affected by rising insulin costs, it makes sense to wonder why prices are so high.
Human versus analog insulins
Today there are two major categories of insulin. Synthetic “human” insulin was introduced in the early 1980s and appears under brand names like Humulin R and Novolin 70/30. Genetically modified “analog” insulin was developed in the 1990s to provide several benefits over human insulin. Analog insulins take effect more quickly, their effects are more consistent and predictable, and they reduce the frequency of low and high blood sugar. Popular analog insulins are Lantus, Humalog, and Novolog. The prices for both types of insulin have risen over the years, but analog insulin is often much more expensive (compare $25 for Novolin 70/30 versus $323 for Humalog 50/50).
Due to the added convenience and benefits of analog insulin, 96% of insulin prescriptions in the U.S. are now for analogs. However, a growing body of research suggests that synthetic human insulin is just as effective for managing diabetes.
Manufacturing insulin is expensive
Producing insulin is more expensive than producing many other drugs. Insulin is a large complex molecule, and to create it manufacturers use recombinant DNA technology to engineer insulin-producing bacteria. In pharmaceutical terms, insulin’s size and complexity deem it a biologic. Because insulin is a biologic, any “generic” versions (termed biosimilars for biologic drugs) are subject to much more stringent–and expensive–approval processes by the FDA.
Because of the expense of producing insulin, even when biosimilar versions are produced, they only reduce costs for the drug by about 20%, compared to an average of 80% reduction for standard generics. Basaglar, the first insulin biosimilar, was introduced in December 2016 and costs around $235.
Elevating prices: the “big three” insulin makers
Just three pharmaceutical companies–Sanofi, Eli Lilly, and Novo Nordisk–manufacture insulin, and they vigorously defend their formulations against cheaper biosimilar versions. Sanofi recently brought lawsuits against both Merck and Mylan to avoid production of biosimilar versions of Lantus, its blockbuster insulin.
What’s more, a recent class action lawsuit against the three manufacturers claims that each of the companies set artificially high prices for their drugs in order to gain preferred status within the insurance companies’ lists of covered drugs. This system of discounting has a few problems. First, the discounts may not be passed on to consumers and instead can raise premiums, copays, or deductibles. Secondly, even those who are insured may be required to pay a portion of that inflated price out of pocket, not to mention uninsured patients who are on the hook to pay even more.
Incomplete insurance coverage raises costs
There are several ways that incomplete insurance coverage can negatively impact patients who use insulin.
The first is when the insurers and payers adjust their list of covered drugs (the formulary) to favor cheaper drugs for their member populations, with the result of cutting out coverage for some drugs that are popular. This made big news in late 2017, when CVS Caremark dropped coverage of Lantus in favor of the biosimilar Basaglar. Consumers who used Lantus were faced with the choice of switching to another brand or paying full price for their drug of choice.
Another factor that has led to higher costs for consumers is the increased use of high-deductible insurance or coinsurance plans. With a high-deductible plan, patients are forced to pay the full amount for insulin until they reach their deductible limit, which can be thousands of dollars each year.
Finally, people who use insulin and have Medicare Part D prescription coverage often find themselves in the “donut hole,” where they’ve surpassed their initial Part D coverage limit but have not yet reached their out-of-pocket maximum of $5,000. During that time, they must purchase insulin themselves, although at a 65% discount.
How to reduce the expense of insulin
The expense of insulin has led some people to cut down their insulin intake, which can be extremely dangerous. Rather than risking your health, try these strategies to reduce costs.
- If you have insurance, make sure your brand of insulin is on the formulary. For example, while CVS Caremark dropped Lantus, they still cover Basaglar, Levemir, and Tresiba.
- Ask your doctor about switching insulins. Human insulin is a fraction of the cost of analog insulin, and biosimilar Basaglar provides a modest cost savings.
- Keep watch for the introduction of Lusduna, a new biosimilar developed by Merck. Approved by the FDA, Lusduna is currently held up due to a lawsuit brought by Sanofi.
- Use coupons available from GoodRx and insulin manufacturers. Information about coupons are available on the GoodRx page for each drug.
- The American Diabetes Association is advocating for lower insulin prices. Go to https://makeinsulinaffordable.org to join the effort and find more resources for lowering costs.
If you do happen to get sick this flu season, you now have the option to take the less expensive generic alternative Tamiflu.
Are you ready? In the United States, flu cases spike in the fall and winter months (although you can get the flu year round). Flu infections peak during December and March but it can linger into May.
If you’ve ever had the flu you know how miserable it can be. The flu can keep an otherwise healthy person out of work or school for as long as 2 weeks.
What is Tamiflu (oseltamivir) used for?
Oseltamivir is used to treat and prevent the flu—specifically, to treat influenza types A and B, in patients 2 weeks and older who have had flu-like symptoms for 48 hours or less. For prevention, it’s only recommended for anyone aged one and older.
What are the common signs and symptoms of the flu?
The common signs and symptoms associated with the flu include fever, body aches, body chills, tiredness, cough, sore throat, headache, and runny or stuffy nose. Be aware if it seems like you or your child may be coming down with the flu—you only have a 48 hour window to start taking Tamiflu after getting sick for it to be effective.
How is generic oseltamivir be available?
No. Brand name Tamiflu is also available as an oral suspension, which does not have a generic alternative yet.
What are the side effects of Tamiflu?
The most common side effects associated with oseltamivir include nausea, vomiting, headache, and pain.
What if I still want to take brand-name Tamiflu?
If you would like to take brand-name Tamiflu, ask your doctor to handwrite “BRAND MEDICALLY NECESSARY” on your prescription. This means the pharmacy is not permitted to substitute with generic oseltamivir.
Otherwise, you can still request that your pharmacist fills the brand for you—just make sure to inform your pharmacist before they fill your prescription.
It may also be a good idea to provide a phone number where the pharmacy can call you and let you know the price ahead of time, as most brands will be quite expensive (with or without insurance) once a generic becomes available. This can save you time and money if you decide the price for the brand isn’t worth it.
Epipens. Sovaldi. Tysabri. Acthar. Harvoni. Every month, it seems, there’s fresh outrage–from president Trump, the Congress, in the media, and among the public–over the soaring cost of prescription drugs.
With good reason: The cash price for the average brand-name prescription drug has increased 48% since 2013. These increases put desperately needed treatments out of reach for many, and cost taxpayers (via Medicare and Medicaid) billions of dollars more every year.
But as expensive as they are, the brand name drugs in the headlines actually treat relatively few people.
Much less attention has been paid to the price of prescription drugs that tens of millions of Americans take every day–that is, the 85% of prescriptions that treat common chronic conditions such as high blood pressure, high cholesterol, chronic pain, diabetes, and depression–and are usually generic medications, not brand-name drugs. Generics are the versions of drugs that get released after a manufacturer’s patent expires, allowing other makers to sell the same compound for less money–well, that’s how it’s supposed to work, at least. More than 3 billion prescriptions are written for generics every year. And the story of generic drug pricing is even weirder than brands.
We should start with the good news: generic drugs are, on average, getting cheaper. Patents on many blockbuster drugs–Crestor, Abilify, Nexium–have expired in recent years, and in some drug categories–statins or anti-depressants, for example–most treatments are now available as generics.
In theory, that should mean cheaper prices. In practice, not so much. Here’s why.
Until the last few years, insurance covered the cost of most generics; patients would chip in an average co-pay of about $10 and never think twice about the cost of their medications. Over the last decade, however, the $10 copay has slowly begun to disappear, and patients are exposed to prices that can vary wildly.
Part of this is driven by Obamacare. The ACA included prescriptions as an Essential Health Benefit, but it also allowed for very limited formularies, (the lists of drugs covered by insurers), extensive use of prior authorizations, (requiring extra approvals from doctor and insurer), and startlingly high deductibles–as high as $6,500 a year for entry-level Bronze plans–before those old-fashioned $10 co-pays kicked in.
At the same time, employee-provided insurance also changed dramatically. Plans that used to provide just one or two tiers of drug coverage now have as many as six, with patient costs ratcheting up with every tier. Meanwhile, copays are being replaced with “coinsurance”, where the consumer’s financial exposure is far greater–a percentage of the total cost, rather than a flat fee.
All this means that the average American has been quickly exposed to what’s called “usual and customary” (U&C) prices, which are the staggeringly high list prices for prescriptions that were never really intended for consumers to actually pay. Think of these prices like the sticker price on a car–most buyers know that the MSRP is a fool’s price, and the real, lower price is hashed out directly with the dealer. Same with the U&C price on drugs, except there’s no back office for consumers to negotiate with.
Take atorvastatin, which came on the market as Lipitor but has been available as a generic since 2011; the cash price for the most common dosage is $120 or more per prescription. Gabapentin, an oft-prescribed pain reliever, has a cash price of $75. Nexium, which went generic in 2015, has a cash price at $250 per fill. The story is even worse with diabetes drugs, including insulin, which are often not covered on insurance formularies altogether, (same with medications for erectile dysfunction and many dermatological conditions).
These prices aren’t just what people without insurance–which still numbers 30 million Americans and could rise substantially if current laws change–will pay. Add up the people in high deductible plans, on Obamacare, and more than 50% of Americans are at risk of paying the full cash price for generic medications.
Fortunately, there are now ways for consumers to comparison shop and access tools to make prescriptions more affordable, even when insurance can’t help. Some pharmacies have created programs to discount limited lists of prescriptions. Manufacturers are beginning to provide discounts and assistance programs to help reduce costs for cash-paying patients. And, over the past decade, pharmacy benefit managers–the companies that actually negotiate prices between manufacturers, insurers, and pharmacies–have launched discount cards that offer lower prices. Together, all of these discounts can provide significant savings; up to 75% off more expensive generics. The company I co-founded, GoodRx, has brought the same technology used to compare prices for plane tickets and TV’s to healthcare. We built a comprehensive database of all available discounts that shows consumers to the best available discount based on pharmacy and location, free of charge. It’s just one solution among many that are needed.
Every year, more Americans are diagnosed with chronic conditions, adding to the 50% of Americans currently coping with such diseases. These are conditions where medicine can’t promise a quick cure, but more typically offers years of coping through one or more medication. For these Americans–which sooner or later will include most of us–it’s essential that any solution coming out of Washington, or out of the drug industry, look beyond the headlines about expensive brand-name drugs, and include the vast number of drugs taken by the vast majority of Americans. If we’re really going to address the high cost of drugs in America, we need to understand the real problem.
This piece first appeared on Quartz
One of the most popular drugs in the country, levothyroxine – also known as the brand name Synthroid – is in short supply, making prices higher and even leaving some patients without the drug. The shortage is a result of hurricanes Irma and Maria, which hit Puerto Rico nearly four months ago, and knocked out manufacturing facilities for many drugs and medical supplies, including levothyroxine.
Walmart, for instance, has more than doubled their cash prices for levothyroxine. Before the shortage, Walmart offered 30 tablets of all dosages of levothyroxine for $4 and 90 tablets for $10. Now, 30 tablets is $9, and 90 tablets is $24.
Walmart issued a statement informing the public of their price increase:
“Effective December 8th, 2017, your price will increase temporarily to $9 per 30-day supply or $24 per 90-day supply. We value your loyalty and business and are committed to offering you affordable pharmacy products and services. We’ll return to regular pricing as soon as this shortage has been resolved.”
In other places, the shortage means that patients are leaving their pharmacy without the medicine altogether. Many consumers are turning to Twitter to share their stories:
At present, the FDA has not added levothyroxine to their official shortage list, even as some patients are being blindsided at the pharmacy over levothyroxine’s cost and availability.
Levothyroxine is among the most prescribed medications in the United States; it is a lifesaving maintenance drug used to treat hypothyroidism. Simply skipping a dose, or waiting till you can afford it it is a dangerous option. Patients who suddenly stop taking levothyroxine may go into withdrawal and may experience symptoms like debilitating weight loss, panic attacks, fatigue, muscle weakness, and nausea.
If you have found it difficult to fill your levothyroxine prescription, or you’re experiencing sticker shock at the pharmacy, here are a couple of alternatives you can try.
Armour Thyroid is considered the natural alternative to levothyroxine. While it is not the first-choice treatment for those with a thyroid condition, according to our friends at Iodine, many people actually prefer Armour Thyroid over levothyroxine. Why? Let’s get into the differences between levothyroxine and Armour Thyroid to explain that.
The main difference lies in how these drugs are manufactured. Levothyroxine is a synthetic T4 hormone, while Armour Thyroid is a natural thyroid hormone. What does this mean? Levothyroxine’s hormone, T4, is not active in the body and has to be processed into a different hormone, called T3, to work its magic. Levothyroxine is also synthetic, meaning that all of the hormones it contains are man-made in a laboratory. In contrast, Armour Thyroid is a natural thyroid, so it comes from animal sources and includes both the T3 and T4 hormones.
Because levothyroxine only includes the T4 hormone, some argue that it might not work for everyone. While studies haven’t shown that Armour Thyroid’s combination T3-T4 therapy is superior to levothyroxine’s T4 therapy, it might account for the high ratings from patients.
Thinking of switching? Here are some things you need to be aware of.
- Birth controls and estrogens have been shown to decrease the effectiveness of Armour Thyroid. Be sure to speak with your doctor if you are taking a birth control.
- Try to avoid antacids within four hours of taking Armour Thyroid, as they can make it harder to absorb the hormones.
- Armour Thyroid and levothyroxine are not interchangeable, so 1 mg of Armour Thyroid is not the same as 1 mg of levothyroxine. It may take some time to determine what dose of Armour Thyroid will work best for you, so as always, consult with your doctor.
- There are no generic versions of Armour Thyroid, and it isn’t covered by many insurance plans, but you can pay as little as $25 with a GoodRx coupon, depending on your location.
- You cannot substitute Armour Thyroid for levothyroxine and will need to get a new prescription from your doctor.
Just like levothyroxine, Cytomel (liothyronine) is another synthetic thyroid medication. But there is a difference. While levothyroxine is a synthetic version of the T4 hormone, Cytomel is a synthetic version of the T3 hormone. Remember how levothyroxine’s T4 hormone has to be processed into the T3 hormone in the body? Since Cytomel contains the T3 hormone, there is no processing needed.
But there is a downside to this. The T3 hormone is absorbed rapidly in the body, which can lead to thyroid hormone toxicity (hyperthyroidism) in some cases. Don’t let this scare you though, Cytomel is safe if used correctly. Be sure to work with your doctor to keep your thyroid hormone levels healthy.
Another downside? According to our friends at Iodine, 13% of people rated that Cytomel was ineffective for them. This side-effect can be common with many thyroid medications, but this is still important to keep in mind.
Thinking of switching? Here are some things you need to be aware of.
- Cytomel has a generic, liothyronine, that is affordable. The average retail price for liothyronine is $33.24 and can be reduced to as little as $12.77 with a GoodRx coupon.
- You may need to work with your doctor to find the right dosage for you.
- Periodic blood tests are a must.
- Cytomel also has many food and drug interactions you should be aware of. For instance, birth control pills, estrogen, anticoagulants, ketamine, antidepressants, and vasopressor medications may interact negatively with Cytomel. Be sure to speak with your doctor if you are taking any of these medications.
- Common side effects include chest pain, diarrhea, weight change, fatigue, headache, insomnia, dizziness, and depression. Be sure to speak with your doctor if you experience any of these for a prolonged period of time.
- You cannot substitute Cytomel for levothyroxine and will need to get a new prescription from your doctor.
Levoxyl (levothyroxine) is a brand name only medication used to treat hypothyroidism and has the same active ingredient as Synthroid – levothyroxine. Just like Synthroid, Levoxyl is also a synthetic T4 hormone. Overall, Synthroid and Levoxyl are quite similar, so why isn’t Levoxyl as well known?
Pfizer, the manufacturer of Levoxyl, lost their market share for levothyroxine products a couple of years back. In 2013, Pfizer pulled Levoxyl from the market because of a suspicious odor emitted from the packaging. After this recall, Levoxyl was off the market for about a year, causing many consumers to switch to alternatives, and they never looked back. Pfizer officially lost their market share. Out of sight, out of mind.
Despite this recall, after Levoxyl’s return to the market, there has been little concern over the safety of the medication, making it an adequate alternative to Synthroid.
Thinking of switching? Here are some things you need to be aware of.
- Levoxyl has a patient savings program that can help you save $5 off your monthly prescription. For more information see Pfizer’s website here.
- While there is no generic available, the brand is still quite affordable, with an average retail price of $33.29.
- Even though they contain the same active ingredient, you cannot substitute Levoxyl for levothyroxine and will need to get a new prescription from your doctor.
For a large portion of Americans, a simple bee sting or a peanut can cause a fatal allergic reaction called anaphylaxis. Fortunately, in most cases, these symptoms can be treated by a shot to the leg with an epinephrine auto-injector. Unfortunately, one of the most popular autoinjectors EpiPen costs around $630 and it’s generic version epinephrine costs around $320 for a pack of two autoinjectors, making them unaffordable for many people in need. But there are other alternatives. GoodRx is here to help explain them.
First off, why EpiPen is so expensive?
You may remember the EpiPen pricing controversy from about a year back, but here’s a refresher.
In August 2016 many patients ordering an EpiPen or EpiPen Jr, the autoinjector for children weighing 33 to 66 pounds, experienced sticker shock at the pharmacy. Those paying cash for EpiPen were hit with a bill for a whopping $600 or more for a pack of two auto-injectors. It soon came out that Mylan had increased prices for EpiPen and EpiPen Jr by 400% from 2011 to 2016.
Why was Mylan able to do this? Because they had the market all to themselves. The main competing autoinjector was discontinued in 2012, leaving EpiPen the only autoinjector available to treat anaphylaxis. With competitors out of the game, Mylan was free to gradually raise the cost of EpiPen more than four-fold without decreasing the demand.
When news broke of the large price hike, the outcry was loud. Top news outlets picked up the story, and Mylan was eventually hit with some lawsuits—sparking a nationwide discussion about drug prices. Mylan attempted to ease the public outcry by releasing an authorized generic version of EpiPen—epinephrine. The outrage, it appeared, had worked, and manufacturers were starting to listen and respond. Or so it seemed.
How much does generic Epipen cost?
Unfortunately, prices are still sky high. Cash prices for a pack of two epinephrine auto-injectors currently average around $377. While this is about 50% off brand name EpiPen, it is still not affordable for many Americans. So how can you save?
Are there any cheaper medications I can try?
We have good news! You have three other choices for epinephrine pens in addition to EpiPen and its generic.
- Adrenaclick (epinephrine). There are a lot of benefits to using Adrenaclick and its generic version. Like EpiPen, Adrenaclick is a pen-shaped autoinjector designed to be easy to use. The main difference? Adrenaclick is affordable. The generic is available for around $100 at CVS and has a manufacturer savings program that can reduce your co-pay to as little as $0 per fill. You can read more about this program here.
- Auvi-Q. During the EpiPen pricing controversy, manufacturer Kaleo made it their mission to develop an affordable autoinjector and released Auvi-Q. The average cash price for Auvi-Q is expensive, but the manufacturer has made it easy for many patients to access it for free through the Auvi-Q Affordability program. You can read more about this program here.
- Symjepi. This one was approved by the FDA in June 2017 and isn’t on the market yet. We also aren’t sure how much it is going to cost, although it is intended to be less expensive than EpiPen. For more information about this approval, read our previous post here.
Is there a reason I should use the brand version of EpiPen?
Not really. All of the autoinjectors work equally well. While it’s might be best to find the most affordable one for you, you should always defer to your doctor.
Generic Epipen still works best for me—can I still save?
- Save with a manufacturer coupon or patient assistance program. Manufacturer Mylan offers a manufacturer program, though it only offers $25 each fill for insured patients. That isn’t much for a $300 medication. You can read more about this program here.
- Use a GoodRx coupon for Epinephrine. GoodRx offers discounts for epinephrine online, which can usually save at least $15 off the full retail price.
- Try to appeal your coverage. If you have insurance and your plan doesn’t cover epinephrine, EpiPen or EpiPen Jr, ask your doctor about submitting an appeal. Some plans require authorizations—meaning you need permission from your insurance plan and a special request from your doctor before you can fill your prescription. If you have insurance, call your provider and ask how to get this process started.