Before he died, my father had a serious problem with diabetes. Managing this disease is challenging enough without being surprised by a high pharmacy bill, or worse, a drug you can’t afford. However, many people find that the price they pay for insulin changes even though they haven’t changed employers, changed insurance companies, or chosen a new health plan. That can leave patients wondering if a mistake has been made or if their insurance company stops paying for their medication.
Insulin prices can change because of behind-the-scenes updates involving pharmacy benefit managers (PBMs), formularies, manufacturer rebates, and annual contract negotiations, not necessarily because your insurance has changed. This is why the price of your insulin may have changed (even if nothing else has).
Your Insurance Plan May Stay the Same, But Your Drug Formulary May Change
Many people think that prescriptions stay exactly the same throughout the year if they keep the same insurance plan. However, insurance companies and pharmacy benefit managers revise their formularies from time to time. Diabetes advocacy groups have talked about the fact that formulary changes often occur after annual contract cycles and can have a significant impact on what patients pay at the pharmacy.
A formulary is simply your insurance plan’s approved list of covered prescription drugs. Medicines are often included in different price tiers, and those tiers can change during annual contract revisions. If your insulin moves to a less popular category (or another type becomes the preferred option), your out-of-pocket costs may change even though your insurance plan remains exactly the same. These decisions are often based on negotiations between PBMs and drug manufacturers rather than differences in how well the drugs work for most patients.
Behind-the-Scenes Negotiations Can Affect Your Out-of-Pocket Expenses
One of the least understood aspects of prescription drug pricing is the role of pharmacy benefit managers (PBMs). PBMs act as intermediaries between insurers, employers, pharmacies, and drug manufacturers. They negotiate discounts, decide which drugs get preferred placement, and influence what most patients end up paying at the pharmacy counter. Their contract decisions can affect the cost of insulin even if the insurance plan itself does not change.
Even if your health insurance stays exactly the same, a different discount agreement can change which insulin gets preferred coverage or how much you pay at the pharmacy. The Federal Trade Commission’s recent actions against large PBMs focused on allegations that rebate practices contributed to higher insulin inventory prices, resulting in payments intended to increase visibility and pass more savings on to consumers.
Your Copay Is Not Always Based on the Actual Cost of the Drug
Many patients understandably think that their copay reflects the actual cost of their insulin, but that’s often not how drug benefits work. Depending on your plan design, your out-of-pocket costs may be combined with the drug’s formulary category, deductibles, coinsurance percentages, or negotiated reimbursement rather than the manufacturer’s list price.
Two people with the same insulin prescription can pay very different prices simply because their employers have chosen different pharmacy benefit plans. This is why insulin costs can be unpredictable even for people with the same insurance. Researchers continue to point to the complexity of the drug pricing system, including manufacturers, PBMs, insurers, pharmacies, and rebates, as a major contributor to patient confusion about insulin pricing.
Medicare and Private Insurance Follow Different Rules
If you’re covered by Medicare, your insulin costs may look a lot different than someone with employer-sponsored insurance. Because of provisions of the Depreciation and Inflation Act, Medicare beneficiaries generally pay no more than $35 for a one-month supply of covered insulin, regardless of whether they receive a deductible. Private insurance plans, however, do not all follow the same cost-sharing rules, although some states and employers have established their own insulin caps. That means two neighbors who take the exact same insulin could have very different pharmacy bills depending on the type of insurance they carry.
Your insulin levels may change because:
- Your program has updated its method.
- Your deductible has restarted.
- Your insulin prices have changed.
- Your PBM has negotiated a new manufacturer agreement.
- The preferred insulin has changed.
- Your pharmacy has changed the reimbursement.
What to Do If Your Insulin Is Suddenly Expensive
Don’t think you’re out of options. Start by asking your pharmacist if an appropriate therapeutic insulin alternative is available under your plan’s current formulary, and check with your doctor before making changes to your medication. Many manufacturers also offer copay cards, patient assistance programs, or savings programs that may lower your out-of-pocket costs if you qualify.
If you recently received a formulary change notice, review the information carefully and contact your insurer’s customer service department to understand your options before you run out of medication.
Before You Leave The Pharmacy
If your insulin levels change suddenly…
- Ask if your insulin is still available in the formula you choose for your plan.
- Ask if a medically appropriate preferred insulin is available.
- Check if the deductible has been reset.
- Ask about manufacturer savings plans or copay cards.
- Check with your insurance provider before skipping doses or changing medications.
- Talk to your doctor before making any insulin changes.
Although some insulin may be covered at a lower cost, insulin products are not always interchangeable. Different forms, delivery methods, and dosage schedules may require medical supervision. Never change insulins without first talking to your diabetes healthcare professional.
Staying Ahead of Future Insulin Price Changes
The price of your insulin is not only determined by the insurance card in your wallet. Annual formulary updates, PBM negotiations, manufacturer rebates, deductible changes, and federal policy all affect what you ultimately pay the pharmacy. Reviewing your prescription each year, reading the notices on your insurance, and asking questions before filling your prescription can help you avoid unexpected costs and maintain uninterrupted access to the medications you need.
If your insulin dose changes unexpectedly, remember that it doesn’t mean your insurance plan has changed. Ask your pharmacist some of the above questions and contact your doctor immediately. They may be able to provide you with tools to help.
Have you ever been surprised by a change in your insulin price even though your insurance has not changed? Share your experience and any tips you’ve found for lowering prescription costs in the comments.
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