Insulin Prices Strike Again

UPDATE: I called OptumRx back to get a price on Insulin Lispro. The rep I got this time told me I wasn’t in the donut hole & didn’t know where the other rep got $2500. My cost for my 9 vials is $400

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I called OptumRx (my Medicare pharmacy benefit) to check on an order of Humalog vials for my OmniPod. I need approximately 3 vials per month because I’m terribly insulin-dependent (CF 1:15, CR 1:5). They told me they hadn’t shipped because my 3-month cost was $2,500. I just got a 90-day supply of OmniPods, which while cheap for me, put me into the donut hole and they’re claiming a cost to them of $10,000 for 9 vials (donut hole price is 25% for brand name).

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I thought insulin was covered under part B if on a pump

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Not for the OmniPod - it’s not considered DME, so neither is its insulin

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Just devastating. When will this all end?

Did you ask them if they ran a test claim for 90 mL of Humalog? Many of them at insurance level can run a test claim. (It may mean you have to speak to a different department then the pharmacy department itself).

I have always been a bit suspicious of Optum RX as a pharmacy. I have had times were their “prices” seem extraordinarily high compared to others. The patient copay may be the same (not in the cases of percentages) but what they claim is cost seems high.
A couple things,

  1. If you have a Costco nearby you may see if you can get a 90 day prescription from Costco (Locally, you don’t have to be a member of Costco to get your prescriptions there…I think it applies to everywhere). Costco is usually the cheapest prices and, if you are paying a percentage, cost matters. Medicare patients can sometimes get a 90 day supply at a local pharmacy despite having a mail-order option available. You’d have to find out. Really, the easiest and fastest way to find out is to have your prescription sent to Costco with your insurance information and have them run it through the plan. If you end up not wanting to get the prescription through them, you can always tell them to cancel it and they will reverse it out of the insurance and you can go with the original idea.
  2. You could see if you qualify for Lilly Cares Program.
    • You have to be a permanent, legal resident of the United States or Puerto Rico.
    • My healthcare provider prescribed a Lilly medication available through Lilly
      Cares, and you have no insurance, or I have Medicare Part D, or, in some
      circumstances, my insurance does not cover the Lilly medication.
      - I am not enrolled in Medicaid, full Low Income Subsidy (LIS, “Extra Help”) or
      Veterans (VA) Benefits. (Humatrope patients may be eligible.)
      - My household income is under the Annual Income Limit.
      - If I am a Medicare Part D patient, I have spent $1,100 on prescription medications
      this calendar year.
      The $1,100 amount counts anything you have paid out of pocket for for medications or things (Omnipods) that come under the prescription benefit. (Part D premiums are not counted).
      The Income Limits for Insulin are:
      Number of people/ in household limit
      1/ $49,960
      2/ $67,640
      3/ $85,320
      4/ $103,000
      5/ $120,680
      6/ $138,360

Thanks. As I wrote, I did call back to check in to pricing for Insulin Lispro and ended up with a different result from a different rep for my Humalog. But between this insulin and the OmniPods (which I get thru a specialty Walgreens mail order pharmacy), I will hit the donut hole soon enough and have to deal with this again.

I agree with you 100% on OptumRx on “list” prices. Sometimes in the donut hole process that helps you, but at others it sucks. I only use them for my insulin & one other name brand med, because at some point they were cheaper, and I get everything else from Walmart, which is identified as a preferred pharmacy with lower prices than Walgreens, CVS and Costco. My Walmart pharmacy doesn’t always employ the brightest techs and it has caused problems getting some things filled. But on generics, the prices at Walmart can’t be beat.

If you are on Medicare you are not eligible for member pricing at Costco or Sam’s Club. Part of Medicare anti-fraud regulations.

That must be a company policy because I find the same true here…

That is a new one…I hadn’t heard that before. I wasn’t talking about member pricing specifically though, just even their general prices are cheaper. I had the PharmD of a different drug store chain tell me once that Costco’s doesn’t mark up their medications as much as other pharmacies. He said that if Costco stopped doing prescriptions tomorrow, they wouldn’t never know the difference in their bottom line. He said (at the time at least) that only about 2% of Costco’s revenue comes from prescriptions.

My omnipod is covered and so is my insulin. I am on Medicare with a supplement insurance. I would rather pay the extra then to payout every time I go to the doctor, hospital, etc.

You mention OptumRX insane prices… I recently switched insurance companies and am now on OptumRX for my mail order pharmacy (only can get 30 days at local pharmacies; I have to do mail order for 90 days).

Yes they show insanely high prices until my insurance kicks in but the only reason I’m using OptumRX is they are the only mail order pharmacy for my insurance so why wouldn’t they be able to show me the price I’ll actually pay?

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My response was about it not being covered under Part B (as DME). I do get mine covered under Part D (as pharmacy). Like you I have a comprehensive supplement and would pay nothing for either if it were covered like traditional pumps. Instead when I hit the donut hole, I am going to have to pay 25% of the list price for Pods and Insulin, which will be expensive.

Are they saying they can’t tell you? Sometimes it is a matter of getting to the right department. It gets confusing sometimes since Optum is both mail order pharmacy and a pharmacy benefit manager (PBM). The pharmacy part of it may or may not be able to tell you your costs without running an actual prescription (and they may or may not be able to run test claims through their end) but the PBM side (or insurance side) might be able to if the pharmacy side can not.

I can’t figure out what benefit Optum has from having really high prices. Since Optum is also the pharmacy benefit manager too, in a lot of cases. To me that is like Optum is charging itself really high prices…What the benefit to that is…I’m not sure.

I found a youtube video that explains this accounting technique: Banana...buck! - YouTube

The high prices are illusory because of the “rebates” (kickbacks). The benefit of high list prices comes when the insured’s copays are based on a percentage of the price. Example (numbers made up for ease of illustration). If my Humalog vials have a list price of $1000, when I’m in the Medicare donut hole, they will cost me $250. Theoretically, that means Optum paid $750 to Eli Lilly. However, Lilly gives Optum a $750 kickback for not using Novolog so Optum only pays $250. Optum got that from me, so actually pays nothing. It makes its money from premiums. If the list price were the actual $250 and there were no kickbacks, I would pay $62.50 and Optum would actually have to pay Lilly $162.50.

Meanwhile, we know that Lilly has long ago recouped its R&D costs on Humalog and it costs
a hypothetical $10 to manufacture. So Lilly is making a hypothetical $240 profit

I know all about the workings of the rebates and have for years. What I find interesting about Optum is that their “list prices” are often substantially higher than other pharmacies. If it were a situation like Rite Aid doing it, and billing a pharmacy benefit manager an high amount, I could figure out the benefit. But Optum RX is both a mail order and a pharmacy benefit manager, they are essentially billing themselves the high cost. I can’t quite figure out the what they are getting out of doing that.

For Medicare, at least, I believe the higher list price gets me into the donut hole quicker, which means I pay more of the cost

Of insulin for a pump is covered in Part B, what would MY cost be- zero?

Medicare covers 80 percent - if you have supp ins they will prob do the remaining 20

Agreed… :face_with_raised_eyebrow: