Express Scripts won’t cover Lilly’s generic insulin

#1

WRITTEN BY: Todd Boudreaux

Express Scripts, the largest pharmacy benefit manager (PBM) in the U.S., recently released a list of formulary exclusions that included ‘Insulin Lispro’ as an excluded medication. Insulin Lispro — the generic version of Humalog recently released by Eli Lilly — has a list price of $137.50, half that of brandname Humalog, which remains on Express Scripts’ formulary. The exclusion does not necessarily apply to Medicare Plans.

Formularies are lists of approved drugs that PBMs/Insurance companies agree to cover on their plans. Exclusion from a formulary means that the new Insulin Lispro will not be covered for those with insurance plans associated with Express Scripts, most notably Cigna (which acquired Express Scripts in 2018).

Express Scripts has not released a statement regarding the decision, but many point to the nature of the complex rebate system behind drug pricing in America as the most likely explanation. When PBMs add prescription drugs to their formularies, they receive a negotiated “rebate” often based on a percentage of the drug’s list price from the pharmaceutical manufacturer.

Additionally PBMs will often only cover one version of a particular insulin (ie. Novolog or Humalog but not both) leaving some patients victims of non-medical switching. If a PBM is only choosing to cover one type of insulin, their financial incentive is to cover the insulin that gives them the best rebates.

In short, the higher the list price of a drug, the more money a PBM stands to gain by including that drug on their formulary.

It should be noted that although insurance companies may not cover the generic ‘Insulin Lispro’, the half-price option will still benefit those without insurance who are paying 100% out of pocket for their supplies. People with diabetes on high-deductible health insurance plans will also have the generic as an option (paying list price) to reduce monthly out-of-pocket expenses before they’ve met their deductible.

This news is the latest in an ongoing debate about who is to blame for the skyrocketing price of insulin in the U.S. Just this month, both PBMs and insulin manufacturers testified before a House of Representatives subcommittee. In what was a contentious hearing, neither party was willing to take responsibility and both seemingly blamed the other for the high list prices.

Indeed, the scrutiny on insulin pricing has been coming from all levels of government. The Senate Finance Committee held a hearing with PBM repson April 9, the FDA is looking at ways to increase competition in the insulin market, and the Trump administration recently proposed targeting the PBM rebate system and instead passing rebates on directly to consumers.

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#2

Considering Express Scripts’ history of fraudulent activity regarding kickbacks and rebate schemes, this should not really be a surprise. There just isn’t enough financial margin in it for Express Scripts to offer the “generic” and make their 1000% profit margin off insurers and insured customers. Sadly, this is a great example of why PBMs should be excised from the Dr/Insurer/Pharmacy/Patient equation. Interjecting a middle level management company sounds great in theory but yet always costs more. The middle level management (PBM) has to make their profit too - off us and the insurance companies. It’s a toxic parasitic relationship that does not benefit anyone except the PBM.

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#3

Fixed it.

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#4

The problem with this is that buying at list price (even cheaper with GoodRX), that cost is not applied to reduce your high deductible.

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#5

It’s like playing a carnival game - completely rigged so less that 10% win.

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#6

this happened to me. I was thrilled to use the Lilly generic for long acting insulin. I went to the pharmacy turned in my script and it was denied by express scripts. I could purchase the Lilly generic for $150.00 per pen (the Lilly copay card would not work because I did not have insurance coverage for the pen) or get 5 pens of Lantus for $80.00. Seems stupid, but what can you say.

By the way, I use one pen a month. Even more stupid.

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#7
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#8

In my insurance plan Express Scripts also changed the conditions for obtaining drugs not on their formulary. Last year it was a $100 co-pay and 80% coverage for the balance. Now it’s a $125 copay plus the difference in list price between the drug you (and your doctor) choose and the formulary version. I could get the generic humalog, but I would pay $262.50 vs. $275 for Humalog. Such a deal!

#9

Just so everybody keeps up hope. I’m pretty sure this is a lot of my efforts right here. They be scared of me, hehehehehe. The prey can become the PREDATORS!!! Stuff takes forever, but things happen. We are hunting for sport, now. Its fun. They entangle in their own snares, hehehehe.

This is them. Slow and steady, but definitely going down…

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#10

There’s a reason US health care is twice the price as other 1st word, but delivers no better outcomes.


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#11

However, the US is where people come that can’t get TIMELY services in their government-run healthcare countries. I hear all the time about how long it takes (if ever) to get a variety of what should be considered urgent services. No thanks. I’ll stay in the US health care system, thank you VERY much.

And I’m not talking about just comments anyone can read online–I converse with people from a number of countries one-on-one and they nearly all have a number of stories to tell about themselves or their friends/loved ones have procedures and tests delayed for ages–often for many months. Health care that isn’t timely, isn’t health care, it’s a system designed to have you die or give up before they have to spend more money on you.

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#12

Express Scripts had 2016 revenues of $100.752 billion.[2]

100,000,000,000 divided by 327,000,000 (population of the US) = $305 per person.

What exactly do these people contribute to health care ?