Recently, major pharmaceutical brands dominating the insulin markets – Eli Lilly, Novo Nordisk, and Sanofi – announced a significant price reduction of their most commonly prescribed insulin products.¹⁻³
To make insulin accessible and affordable for over 8.4 million Americans who require it daily:⁴
Eli Lilly announced March 1 it is cutting the list price of its most commonly prescribed insulin lispro (Humalog), by 70%, effective from the last quarter of 2023.
Following suit, Novo Nordisk announced on March 14 that it will be lowering the US list price of several insulin products, including insulin detemir (Levemir), insulin isophane (Novolin), and insulin aspart (Novolog), by 75%, effective on January 1, 2024.
Sanofi announced on March 16 that it would be lowering the list price of its most widely prescribed insulin glargine injection (Lantus), by 78%.
All three pharmaceutical companies are capping out-of-pocket costs at $35 per month for people with commercial insurance and streamlining different insulin value programs for people without coverage.
This announcement comes after the recently enacted Inflation Reduction Act set the insulin cost-sharing limit to $35 for seniors enrolled in privately run Medicare plans – Medicare Part D and Medicare Part B.⁵
“It is pathetic that we took this long to get here,” said Deena Adimoolam, MD, an endocrinologist in Clifton, NJ. “Insulin has been available since the 1920s, and it is cheap to produce, yet the cost of insulin has increased over the years, making many people who require diabetes care ration their insulin,” she said.
After its discovery, insulin was initially patented for $1, yet today, more than 1 million Americans cannot easily afford it.⁶
According to Ishita Patel, MD, an endocrinologist in Austin, TX, “Any cost cap is always good for the patient and the healthcare system. The easier it is to prescribe and afford insulin, the better patients can effectively maximize its use. And the more insulin is utilized appropriately, the easier it is for healthcare providers to achieve better health outcomes,” she explained.
Insulin Pricing and Access
The price of insulin in the United States has been at an all-time high. A 2022 study published in the Mayo Clinic Proceedings showed that:⁷
The average American paid a minimum of $3,490 as out-of-pocket costs on insulin as opposed to the average Canadian, who spent $725 for the same medication in 2018.
The average cost-per-unit of insulin increased by 10.3% from 2016 to 2019.
Insulin prices in the US are significantly higher than in other countries, forcing many Americans to cross the border to purchase insulin in Canada at much lower prices.
A 2021 comparative analysis examined insulin costs in 33 nations of comparable income levels.⁸ According to the authors, the average list price of a single vial of insulin costs $6.94 in Australia, $7.52 in the UK, and $14.40 in Japan. Insulin in the US was the highest at $98.70 – four times as much as the next most expensive country, Chile, at $21.48 per vial.
Three pharmaceutical firms are key players in the analog insulin market, accounting for over 90% of insulin sales in the United States. Eli Lilly manufactures the fast-acting insulin lispro Humalog, Novo Nordisk produces insulin aspart Novolog, and Sanofi offers the long-acting insulin glargine injection Lantus.¹⁻³
Since they entered the US markets, the list prices for all three products have increased significantly. A 2000 to 2018 report by the Human Rights Watch noted the following inflation-adjusted costs:⁹
Humalog costs $21 per vial when it first entered the US in 1996 and rose to a $275 list price tag.
Novolog increased by 403%, reaching $289 per vial.
Lantus increased by 420% to $276 per vial.
Currently, the retail prices of these brands each cost over $300 per vial. And given that people with type 1 diabetes may need 2 to 3 vials of insulin per month, out-of-pocket costs may reach an annual expenditure of more than $12,000.
Why Is the Price so High?
“Insulin is a ‘biologic,’ which makes it more complicated and expensive to replicate than a generic. When there was no competition, pharmaceutical companies like Lilly and Novo Nordisk could maintain control over insulin prices and charge higher costs,” Dr. Adimoolam said.
“The US patent system is another barrier to promoting cheaper versions of insulin. Drug manufacturers are continuously making new small changes to their insulin products, and applying for new patents makes it harder for small competitors to keep up,” she noted.
A 2013 article published in the Canadian Medical Association Journal suggests that elevated insulin prices may be due to “evergreening” – a common practice used by pharmaceutical companies to extend the patents of some brand-name prescription medications by slightly modifying older formulations over time.¹⁰ While evergreening may improve drug delivery, it prevents unauthorized exploration from competing pharmaceutical brands, causing retail costs to skyrocket.
Access and Rationing
According to a study published in the Annals of Internal Medicine, high costs and inadequate insurance coverage may hinder access to insulin.⁶ For the research, Gaffney et al analyzed a 2021 National Health Interview Survey (NHIS) to determine the prevalence and correlates of insulin rationing. The survey asked adult insulin users whether they skipped insulin doses, took less insulin, or delayed buying insulin to save money.
The sample included 982 insulin users with diabetes, representing 1.4 million people with type 1 diabetes (T1D), 5.8 million people with type 2 diabetes (T2D), and 0.4 million people with other or unknown diabetes types.
The researchers noted the following findings:
16.5% of insulin users, or 1.3 million adults living with diabetes, rationed insulin in the previous year
Taking less than needed was the most common form of rationing among people with T1D
Uninsured persons had the highest rate of rationing, followed by those with private insurance (18.8%), other coverage plans (16.1%), Medicare (13.5%), and Medicaid (11.6%)
Effects on Health Outcomes and Medical Practice
According to another 2022 study, high out-of-pocket costs (OOPC) for insulin can lead to cost-related nonadherence and poor outcomes prompting patients to limit insulin use.¹¹ Individuals with T1D were more likely to have a 60-day gap in insulin supply when the OOPC was more than $50 per month supply and with the OOPC more than $35 in people with T2D.
One article also found that the prevalence of insulin underuse remains high in primary care, and healthcare providers should regularly assess medication cost barriers with all patients.¹²
“The high costs of insulin influence how people choose to use their insulin daily. Many of us have stories of patients who ration their insulin because they do not have the money to buy more insulin,” Dr. Adimoolam said. “This can cause high blood sugar and worsening diabetes control, leading to diabetes ketoacidosis (DKA) in a few unfortunate instances. Insurance companies do not realize that the cost of a DKA hospitalization is 10 times more than the cost of covering that person’s insulin for the month,” she noted.
“It is an added stress on the system for us as physicians to be unable to prescribe the appropriate insulin in a timely fashion for our patients due to the barriers created by the US healthcare system,” Dr. Patel added. “Sometimes it can take several weeks to approve medications we deem necessary, and each day is an increased risk for the patient,” she said.
Clinical Takeaways
To best treat people living with diabetes under these circumstances, Dr. Adimoolam and Dr. Patel recommend the following tips to healthcare providers:
Communicate with patients to ensure they can afford their insulin
Ask about their insurance plans and whether or not it covers insulin
Prescribe cheaper alternatives to common brand-name insulin
Educate all insulin-dependent persons on the different types of insulin as well as how to obtain and dose them
Enlighten people living with diabetes on the importance of having provider-patient discussions before switching an insulin dose or medication
“Cheaper access to medications will ultimately allow for better diabetes management,” Dr. Adimoolam said. “Smaller pharmaceutical companies like BiologX are entering the market to manufacture cheaper versions of insulin. This competition will help to keep overall insulin prices lower,” she said.
