In case you missed the recent headlines: One of the largest insurance companies in the country has made a move to cap copays for insulin at $25 for a month's supply, attempting to broaden access to this life-sustaining medication that's become the poster child for outrageously high drug pricing in America.

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Announced on April 2, the combined company of Cigna and Express Scripts -- which finalized a $67 billion merger at the end of 2018 -- plans to offer its members in participating plans a Patient Assurance Program that will cap out-of-pocket costs (deductibles, copays, co-insurance) for insulin at $25/month max. The new program will be finalized by year's end for Express Scripts members, and the start of 2020 for Cigna members.

This comes at a time of increasing pressure over skyrocketing insulin prices in America, with multiple Congressional hearings underway -- including one today before the Senate Finance Committee with insurers and Pharmacy Benefit Managers (PBMs), and one tomorrow (4/10/19) involving the big three insulin makers being called to testify in front of a House panel. The current Insulin Pricing Crisis is a system-wide issue that has bubbled to the top of public consciousness, and is thankfully now being heatedly discussed at both the federal and state levels.

While Cigna and Express Scripts' new $25 copay program is "only a band-aid" for certain people who have particular insurance plans that opt in, it is being called "a step in the right direction" by vocal advocates who recognize that it will help many people couldn't otherwise afford the insulin they need to survive.

We reached out to Cigna/Express Scripts to answer the many questions that come to mind for PWDs (people with diabetes) like us:

 

First off, how many PWDs actually stand to benefit from this?

More than 700,000 people enrolled in commercially insured plans across Cigna and Express Scripts had filed a claim for insulin in 2018. So that is the potential population for this program, Cigna says.

 

Many news stories report that the average Cigna/ES member is only paying $41 a month for insulin prior to this program, which is already fairly affordable...?

The devil's in the details, of course. Cigna states that for the average Cigna/Express Scripts member, the price of a 30-day supply of insulin is only $41.50, while for those on High Deductible Health Plans (HDHPs) it's $81/month, and up to $100/month for those on HDHPs in which insulin is not on the preventative drug list where deductibles don't apply.

Those amounts may not sound exorbitant, but what they don't take into account is that early in the year, prior to meeting an annual deductible or coinsurance requirement, many people are exposed to high costs and thus unaffordable insulin. So while a copay may hit just $41.50/month at some point late in the year, the truth is that for many months before that happens, the cost is hundreds of dollars higher. So yes, Cigna has some feel-good numbers to share, but they are a bit misleading and don't reflect reality.

Cigna says this new Patient Assurance Program will amount to members' annual costs dropping from $1,000 to $250 -- which is meaningful however you slice it.

 

Wait, members will only have to pay $25 -- and not meet their deductible first?

Yes, that's correct. For those higher deductible plans, this moves insulin to a "preventative drug" category in which the deductible wouldn't apply. Instead, the low copay is available immediately.

 

What insulins are being offered through this program?

All three big insulin manufacturers -- Lilly, Novo and Sanofi -- are participating, according to Cigna/ES. We're told they plan to include both short-acting and basal insulins, but a full product list isn't yet available.

We were immediately concerned about "preferred brand" status that could lead to another "formulary war" where drug makers jockey to get better access and lower copays ahead of their competitors, but Cigna insists the program will not have an impact on formulary status.

 

How much insulin do members get for that $25 copay?

The cost is $25 for a month's worth of each patient's individual prescription of insulin, whatever amount that may be and whether it's in vials or pen cartridges.

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But what if my Cigna insurance plan requires me to get 90 days of insulin rather than a single month's worth?

You will still benefit, Cigna says. The copay for a 90-day supply, whether via mail delivery or retail, will be $75.

 

When does this program begin and end?

The powers-that-be tell us they expect it will launch for Express Scripts members before the end of this year, and for Cigna members beginning in 2020. This is not a pilot or trial program, and there's no end-date attached at this time.

 

Why not just lower list prices for all insulins offered through Cigna?

That's a separate issue, we're told (and given the convoluted nature of drug pricing including industry rebates and kickbacks, we're not surprised).

 

So how is this being paid for?

We wondered whether Cigna Corp. was absorbing the overhead costs. As it turns out, the participating drug makers (Lilly, Novo and Sanofi) are all providing an additional discount applied at the point of sale to push the copay down to $25. Sadly, this doesn't eliminate the issue of established rebates in broader insulin pricing, we're told.

 

How do I know if my employer has signed up to participate in this?

"We are not able to just automatically apply it to our clients," a Cigna spokeswoman said. "They have to agree to participate because it’s their benefit. We are going to encourage all clients to implement this as a program, and feel confident most will be eager to implement it."

There is no charge to participate, and Cigna assures us that "most plans" will not see any additional cost to get the co-payment down to $25 for the patient. Employers interested in participating can learn more about during open enrollment periods (annual insurance discussions when plan designs are evaluated), and are welcome to contact Cigna/ES to find out more.

 

What about Medicare and Medicaid? And those without insurance, or who aren't covered by Cigna plans?

To clarify: Sorry Folks, this will not apply to those on federal plans. It's a program specifically offered by Cigna and Express Scripts for their members.

 

Will other insurance companies follow suit?

We certainly hope so. When asked for a comment on that, a Cigna spokesperson provided this statement: "Our job is to provide better care, more choice, and greater affordability. Our Patient Assurance Program offers all three. For customers and members who rely on insulin, Cigna and Express Scripts have found a way to deliver greater affordability and peace of mind to these patients, and we are confident that our new program will remove cost as a barrier for people in participating plans who need insulin. We’re also glad the manufacturers are able to work with us to make it happen."

 

Why is this happening now?

Good question. We wondered if it was a direct result of the new federal Health and Human Services (HHS) proposal to eliminate drug rebates... but Cigna says they have been working on this concept "for a while" and were finally able to make it materialize following the Cigna/ES merger finalization in December 2018.

We still think it's pretty coincidental (and likely planned) that this move comes just as insurers and PBMs are being summoned before Congressional panels over drug and insulin pricing.

 

Right. Isn't this just another PR move to take the heat off payors and other decision-makers on drug pricing?

Some may roll their eyes, saying it's only a PR move -- but while there may be truth to that, it still helps.

Just like the recently announced half-price Insulin Lispro from Eli Lilly, this is nowhere near a final solution to America's Insulin Pricing Crisis, of course. No one claims it is. But just like with that offer, if one more family can afford the insulin they desperately need, then it's a win for our Diabetes Community.

The advocacy doesn't stop here, of course. We continue to cheer on the many insulin pricing advocacy initiatives and efforts to call manufacturers and PBM middle-men to task. Here's to slowly but surely moving the needle on insulin access (no pun intended).