Lately the national news has been covering people with diabetes trekking to Canada or Mexico in desperate search of more affordable insulin. This certainly isn't a new phenomenon, but it's making headlines more frequently now because of the continuing Insulin Affordability Crisis in America.

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At this point, no one really needs to ask why Americans are crossing borders to get their life-sustaining insulin. That's quite clear, given the skyrocketing prices leading to rationing and even death, while drug prices are up to 80% lower outside the country. Rather, the media coverage is causing many to wonder why they hadn't turned to this option before, even amid questions about legality and safety.

It is in fact one of those practices that's technically illegal, but has been "decriminalized" with a general policy exemption for individuals. That means for many years the authorities -- in this case the FDA and Customs and Border Patrol -- have allowed citizens re-entering the country to bring limited amounts of medications needed for their personal use.

Personally, I know it's possible to bring in insulin for individual use because I have done it. I have driven to Canada from my home in Michigan on several occasions and purchased the insulin I need. While my experiences there have varied from pharmacy to pharmacy, I've not once encountered an issue that thwarted my mission.

Cleary, I'm not alone.

 

Insulin-Buying Caravans in the News

Four high-profile group border-crossing trips for affordable insulin have made national news in just the first months of 2019, and others are reportedly in the works. That media attention is bringing a new level of conversation about the practice that our Diabetes Community hasn't seen before.

  • In February, a D-Community group traveled from California to Tijuana to buy insulin
  • In March, a Pittsburgh, PA, group traveled together to Canada, making a 250-mile trip.
  • In early May, a group from Minneapolis made a 300-mile trip north to Fort Frances, Ontario, to buy insulin. In that case, the idea was first floated in a Facebook group by D-Mom Lija Greeseid and eventually attracted several others from the area including well-known D-advocates Quinn Nystrom and D-Mom Nicole Smith-Holt (who lost her 26-year-old son Alec due to insulin rationing because of high prices)
  • Also in early May, a group of five people traveled from Metro Detroit to Windsor, Ontario, for the same reason, with a group leader calling ahead to reserve the requested insulin so it would be in stock when they arrived

Media stories and our own conversations with some involved in these treks confirm that no issues arose -- not from pharmacists willing to sell them insulin, nor any hassles from border patrol agents on the way back into the USA.

While costs do vary between Canadian provinces, insulin across the board is extraordinarily less expensive than in the United States: from $30 to $45 for a vial of fast-acting insulin like Humalog or Novolog (called NovoRapid outside the USA) versus ~$300 in the USA; and roughly $60 to $100 for a box of pre-filled insulin pens, versus upwards of ~$500 or more in the U.S. And if someone's buying multiple vials or pens, just do the math -- it's quite the difference in price.

Wow!

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The Minnesota #insulin4all group that traveled to Canada for affordable insulin

Many of those making these trips self-identify as #insulin4all advocates who are active in T1International, a UK-based global nonprofit that's been focused on affordable insulin since its launch in November 2014. It now has chapters in more than half the U.S. states, and has led protests in front of Pharma companies that have helped generate a steadily growing drumbeat of media coverage and political influence.

Word is that these same groups are planning more trips, possibly even larger caravans, and asking some participants to transport insulin back into the USA for others who might be in need.

 

My Trips to Canada for Insulin

The first time I tried this myself was in 2015, following our move back to Michigan and when my wife and I were suddenly caught off-guard by exorbitant insulin prices due to an insurance change. Basically, the mid-year move left us exposed unexpectedly to a high deductible. Because we'd been using my wife's insurance coverage for the first half of that year and hadn't touched my HDHP (high deductible health plan), we suddenly realized we had a scary-high amount to pay before any coverage would kick in for my medical supplies, including insulin.

I panicked.

Fortunately, I knew options existed. I am privileged to have friends in the Diabetes Community who offered to help by sending me some surplus vials. I also knew that in a worst-case financial scenario, I could always turn to Walmart's $25 insulin option to bridge the gap until my wife's new insurance coverage kicked in -- although that's an old-school insulin formulation that's certainly not ideal therapy for most people now using analog insulin brands.

At the time, I was vaguely aware of the Canadian insulin option but didn't fully grasp whether it was something I could actually do myself. So I decided to investigate by driving to Windsor, a Canadian town just across the Detroit River within 30 minutes from where I live in the Metro Detroit suburbs.

That first time walking up to the counter in a small pharmacy just outside of Windsor is still fresh in my memory. I probably looked terrified, as if I were taking part in some illegal cloak-and-dagger smuggling operation. I had studied information online, as well as the applicable laws, before my travels. But it didn't alleviate my concerns.

"I'm here to buy insulin...(?)," I choked out nervously, my voice rising at the end in more of a question than a statement. I certainly expected some third degree from the pharmacist behind the counter. But nothing like that happened. It was surprisingly uneventful and easy -- easier than it often is here in the States, where pharmacies require a lengthy process of verifying information before we ever get to discussing the needed medications.

The cost comparison was striking: I paid less than $50 U.S. currency for a bottle of the Humalog I was using in my insulin pump at the time. By comparison, a single vial of that elixir in the U.S. processed through my insurance pre-deductible would have been four times the price, at over $200 then (whether purchased at a local pharmacy or via mail order).

As others have reported about their own international-travels-for-insulin, I was beyond relieved and elated to actually find affordable insulin. I felt a sting of rage that it's even necessary to go to these lengths, but also grateful that our D-Community has this potential option if there's a personal need.

Clearly, I'm not alone. I've also talked to many others in my Metro Detroit and Great Lakes region who have made these trips to Canada for insulin. One longtime type 1 says her insurance doesn't cover the particular brand of insulin that her doctor has determined is best for her, but she can't afford the thousands it would cost each month out-of-pocket. So, she crosses into Canada from Southeast Michigan and buys it there for about a tenth of the price (!) of what it would cost here.

Others report similar savings and reasons, from challenges with Non-Medical Switching on insulin brands to high-deductibles or even no insurance where they must pay the retail list prices.

That's why we do this.

Sure, I could've bought more insulin to stockpile. But I opted not to, because of both my caution as well as awareness that I had access to other emergency options in the U.S. and didn't need to push my luck in Canada.

I've repeated this since then, but usually on the way home from a Canada trip when I was already in the country for some other reason. I've also pondered purchasing larger quantities for myself, or responding when someone else has asked me to buy insulin for them while there, but I decided against it because it wasn't a personal emergency or necessity. That just didn't feel right to me.

Because yes, there are some rules in place.

 

Getting Insulin Without a Prescription?

While you don't officially by law need a prescription to buy insulin in Canada, not every pharmacist knows this and some have actual unwritten policies of requiring you to show one and verify it before filling the script. I've had a couple encounters in places where the pharmacist didn't know the letter of Canadian law stating that a prescription is not required. Once I had to ask the pharmacist to look it up, and whala! -- it all worked out. Another time an individual wouldn't sell me insulin without a prescription on file, even though I had a paper copy. I simply walked out and went to find an alternate pharmacy, where the purchase was made without incident.

Each time, I've only bought a single vial and have paid cash. And I always declare my Canada-bought insulin and have the written documentation ready at the border crossing, even though I've never needed to show it. Just once at the smaller border crossing in Port Huron, Michigan, the CBP agent did ask if my insulin was for "personal use" and I responded that it was -- indicating that some agents are on the lookout for folks importing meds with the intention of reselling them.

 

FDA and Medication Imports

The FDA's guidance on "personal importation" actually states: "In most circumstances, it is illegal for individuals to import drugs or devices into the U.S. for personal use because these products purchased from other countries often have not been approved by the FDA for use and sale in the U.S. For example, a drug approved for use in another country but not approved by the FDA would be considered an unapproved drug in the U.S. and, therefore, illegal to import."

But the same guidance also lays out that exemptions are permissible if:

  • The medication is for personal use.
  • The quantity is generally not more than a 90-day supply and the person importing it can either:
    1. Provide the name and address of the doctor licensed in the U.S. responsible for their treatment with the product, or
    2. Provide evidence that the product is for the continuation of a treatment begun in a foreign country.

 

Concerns About Importing Insulin

All the recent media coverage about this topic -- including the flashy "Caravan to Canada" story all over newspapers and TV -- is of course helpful to shed light on our Insulin Pricing Crisis. It's outrageous that people with diabetes must flee their own country in order to get affordable insulin in the first place.

But two points about all this do cause me some concern:

Prescription Rules: First, the fact that you don't need a prescription to buy insulin over the counter in Canada or Mexico. This can be liberating in many ways. But as mentioned, not all pharmacists know that, so American patients may end up frustrated or in arguments with local pharmacists, which could cause trouble. Also, border patrol agents still have the right to demand to see a prescription before allowing you to bring back any medications into the USA. So all the media coverage screaming "You don't need an Rx!" can be a bit misleading; some folks may end up more confused and disillusioned than anything else.

Personal Use vs. Public Policy: Secondly, like just about everything else these days, this notion of bringing in medications from outside the country is politically divisive. Lobbyists and Pharma folk are pointing to "safety concerns" whenever this comes up. While I may not necessarily agree that's an issue for personal importation, I am nervous that all the media play will start raising red flags and catch the attention of policymakers here. An unintended consequence could be more push for the FDA to crack down on the "exemption policy" that's traditionally allowed everyone, including border patrol, to look the other way.

It's one thing if people are crossing the border individually or in small numbers, but when you start seeing organized efforts where there's energy spent on making calls, taking orders and planning out the "How To" aspects of an international trip, it becomes a coordinated movement. Not that anything being done is nefarious, but the larger group could become a target of those who might not want to see this practice continue.

So far there's no evidence that anyone has attempted to buy and sell insulin from outside the U.S. for a commercial profit. But eventually, some profiteers may catch on. I hate to be cynical, but that's sadly how our world works and often bad apples spoil the bushel for the rest of us.

My big hope is that in these desperate times, the desperate measures we are forced to take will serve to highlight the need for a solution, rather than just open up another avenue for exploitation.