Mark Harmel, MPH, CDE is a diabetes educator and clinical research coordinator at the USC Westside Center for Diabetes and a contributor for Medscape. His public health training drives his interest in soda taxes and participation in the Diabetes Prevention Program to prevent type 2 diabetes. Mark’s research projects and patient education focus on how people with type 1 diabetes can best use continuous glucose meters and insulin pumps. @MarkHarmel
Have you ever received a letter from your insurance company telling you that you have to change the brand of glucose meter, oral medication, or insulin that you use? You are not alone, but why does this happen and who is responsible?
You can thank your pharmacy benefit manager (or PBM). These are the companies who partner with your insurance carrier who claim to have the goal of reducing drug costs and improving care. Your PBM is likely to be Express Scripts, CVS Health, or OptumRx.
The ole switcharoo
On the plus side, PBMs can save money by switching patients from the branded cholesterol drug Lipitor to the generic atorvastatin, for example, but it can get much more complicated when a person with type 1 diabetes (a T1D) is switched from Humalog to Novolog.
People with diabetes trust their routine and many have only used one brand of fast-acting insulin or one type of meter their entire life. Being forced to make a change can be a big deal. A switch from one leading brand like OneTouch to an Accu-Chek meter doesn’t affect accuracy that much, but being asked to use a less-accurate generic brand meter can be dangerous for a T1D—or a burden if a meter is paired with an insulin pump.
Either you—or with luck, your healthcare team—can help fight the bad changes, but these battles can take hours fighting through phone trees and trading faxes to get the proper treatment approved. This can waste countless hours, increase you blood pressure, and have mixed results.
Rebate or kickback?
To make the situation even more complicated, the deals cut by your PBM to get cheaper drugs could be making them money as well. The discounts are paired with sales incentives and “rebates” back to the PBMs that can look a lot like kickbacks. These rebates are hidden in a black box and some think this is one of the reasons for increased insulin prices, while these same companies complain about the need to cut costs.
When and how to fight
When your health is at risk, take the time to fight and try to enlist your healthcare provider to help. Even if you do your research, the PBMs don’t always listen to reason. They have people in front of a computer checking boxes deciding whether to approve your request—or, too often, not approve it. Often it is as simple as saying, for example, that you tried taking metformin and it failed so you need to take another drug. The metformin box needs to be checked before you can move on to an alternative, so try to recall that diarrhea episode back in 2014.
Having a meter that pairs with a pump can also be approved after a fight, but some of your wrath should also be vented at Medtronic, who made the deal to pair their pumps with the high-priced Bayer/ Ascensia strips. You can also try ordering the strips directly through Medtronic to get the strips approved.
Savings cards and sites
All the drug and major strip companies offer savings cards that could help you continue with your favorite brand. These can work if you have commercial insurance (not Medicare or Medicaid), but may drive up overall prices. The website GoodRx can help you shop for a better price and deals can be found at Costco pharmacies where you can fill your prescriptions without being a member.
Good and bad changes
Metformin is cheap, safe, and still considered to be the initial drug choice for treating type 2 diabetes. It is also weight neutral and has heart-health benefits. Try it or try it again to see if you can get past the mild gastrointestinal side effects.
The TZD class of drug Actos (pioglitazone) targets insulin resistance and was a wonder drug when it came out, but a heart-risk scare in 2007 caused it to fall out of favor. After additional research, the cloud lifted and there is new interest in the now generic pill.
Basaglar is the new biosimilar basal insulin that is equivalent to a generic Lantus (insulin glargine). The 15 percent savings could help break the spiral of rising insulin prices and be a good choice for people with type 2 diabetes. But T1Ds may want to fight to stay on the new and longer-acting Tresiba (insulin degludec) or Toujeo (insulin glargine U300) that reduce the risk of low blood sugar.
A change to Jardiance (empagliflozin) in the SGLT-2 inhibitor class could be good for your heart after recent news showed a 38 percent risk reduction for heart-related death in people with type 2 diabetes who have a high risk of heart disease. Similar good heart health and kidney news was reported for Victoza (liraglutide). This is a once daily injectable in the GLP-1 agonist class. It you were switched off one of these drugs you should talk with your doctor and fight to go back on them.
Have you had coverage problems with your preferred prescription brands? Share your experience and advice by commenting below.