The purpose of this article is to help you make the most of your prescription drug insurance. There are 4 sections of this article. Click the links to navigate to the sections faster.
The formulary is the official list of medicines your insurance will pay for. For diabetes medications, there are about 10 drug classes commonly used. In each drug class, there are often 3-5 brands of medication. Your insurance will typically have 1 or 2 brands of drug from each drug class on the formulary. If a diabetes medication is not on the formulary, then it is unlikely to be affordable. Therefore, you need to know how to access your formulary! They used to send out formulary books every year, but now it is typically just on a website. Know how to log in and find it. Drugs included on the formulary list can (and often do) change from year to year. So a medication on formulary this year may not be next year, so at the beginning of each year you may need to check the formulary again.
There are 5 elements to understand about a formulary:
Knowing that a medication is on the formulary is just the beginning to figuring out is you can afford it. The next step is to determine if there are restrictions on the medication. If there are restrictions on the medication, You will not have access to it unless you have met the requirement(s) to remove the restrictions. For example, many insurance plans will not pay for the drug class GLP-1 medications if you are not already taking metformin (or previously took it and cannot take it any longer). This restriction is also referred to as step-therapy or a step edit. Step therapy is a policy that requires you to first try a lower-cost drug that has been proven effective for some people with your condition before you can “step” up to a more expensive drug.
If the medication is on formulary, and you have met requirements for any restrictions, there still may be a prior authorization required. If the drug is listed as being available only by prior authorization, that means that your insurance company has a hidden set of rules that govern when the drug will be covered. Yes, you read that right. They do not publish this information and do not make it available to you or to your physician. Your doctor has to submit answers to a series of questions. Depending on their hidden criteria, the answers will earn you prior authorization, or they will reject the medication and not cover it.
OK, so the medication is on the formulary, you have met any restrictions, and you’ve gotten over the hurdle of the prior authorization. This means you can use the medication, right? Well, you can, but you still may not be able to afford it if it is not on the right “Tier”.
Most prescription drug plans place prescription drugs into different “tiers”. A drug in a lower tier will cost you less than a drug in a higher tier. Your insurance plan may have just 3 tiers, or may have upwards of 7 tiers! Below is a common example of how a plan might divide its drug tiers:
Key Point: The “preferred brand” tier is the sweet spot for brand drugs, and you want to know which diabetes drugs in your formulary are in this Tier every year. However, you can often afford the “non-preferred brand” tier drugs if the drugmaker has a copay coupon.
Alright! The drug is on the formulary, no restrictions, passed the prior authorization, and the drug is on a preferred tier. The drug should be affordable, but there is one last element to consider. Do you have a deductible, and if so, how much is it? Your deductible is the set amount you need to spend each calendar year before your plan’s benefits kick in.
Some insurance plans apply the “general medical” deductible to prescriptions as well, which means that the plan won’t make any payments for your medications until you’ve met your entire medical deductible. Other plans have a lower deductible that applies just to prescription coverage. You need to know which one you have!
Key Point: All patients with diabetes need to know what their yearly prescription drug deductible is!
The amount you pay for each prescription after you’ve paid your deductible is either a copayment or coinsurance. Copayment and coinsurance are not the same thing, and your insurance will have one or the other for prescription drugs. You need to know which it is. If you have the choice between prescription drug plans, you will almost certainly want one that has copayment rather than coinsurance.
If you have commercial drug insurance, you may be able to lower your prescription drug cost through a copay coupon (this is also referred to as a copay assistance program). Copay coupons typically will only work if you have commercial insurance (so most of these will NOT work if you are uninsured, have Medicare part D, or have Medicaid). There are 2 notable exceptions, both with regard to insulin. Sanofi (who makes ademlog, apidra, lantus, and toujeo) and Novo Nordisk (who makes novolog, fiasp, tresiba, levemir, and novolog mix) both now have programs where you can get combinations of their insulin products for $99 a month, even if you do not have insurance. These programs are separate from their other co-pay card programs.
Find your medication in the table below and click the link to go to the manufacturer website. Complete the online form to get the coupon. You can either print out the coupon to take to the pharmacy, on just pull it up on your phone at the pharmacy.
|Drug||Co-pay card available? (Click for link to card)||Copay Card Details||Must have commercial insurance for copay card?|
|Ademlog ($99 program)||Valyou program||30-day supply of a combination of Sanofi insulin products (up to 3 vials or 2 packs of pens) for $99 for up to 12 months.||No|
|Afrezza||Co-pay card||Max $300/month savings||Yes|
|Apidra||Co-pay card||$0 copay with max savings of $150 PER PACK of lantus. (note that there is also a separate program for uninsured.cash pay patients.)||No|
|Apidra ($99 program)||Valyou program||30-day supply of a combination of Sanofi insulin products (up to 3 vials or 2 packs of pens) for $99 for up to 12 months.||No|
|Basaglar||Co-pay card||Max $150/month savings||Yes|
|Bydureon||Co-pay card||Max $150/month savings||Yes|
|Byetta||Copay card||Max $150/month savings||Yes|
|Farxiga||Copay card||Max 378$/month savings||Yes|
|Fiasp||Copay card||Max $150/month savings||Yes|
|Fiasp ($99 program)||My99insulin||30-day supply of a combination of Novo Nordisk insulin products (up to 3 vials or 2 packs of pens) for $99 for up to 12 months.||No|
|Humalog Mix 50/50||No||N/A||N/A|
|Humalog Mix 75/25||No||N/A||N/A|
|Humalog U200||Copay card||Max $100/month savings||Yes|
|Invokana||Co-pay card||Max $200/month savings||Yes|
|Invokamet||Co-pay card||Max $200/month savings||Yes|
|Humulin R U500||Copay card||(? Max savings). Counts toward deductible||Yes|
|Januvia||Co-pay card||Max $150/month savings||Yes|
|Jardiance||Co-pay card||Max $550/month savings||Yes|
|Lantus||Co-pay card||$0 copay with max savings of $150 PER PACK of lantus. (Note that there is a separate program for uninsured/cash-pay patients)||No|
|Lantus ($99 program)||Valyou program||30-day supply of a combination of Sanofi insulin products (up to 3 vials or 2 packs of pens) for $99 for up to 12 months.||No|
|Levemir||Co-pay card||Max $100/month savings||Yes|
|Levemir ($99 program)||My99insulin||30-day supply of a combination of Novo Nordisk insulin products (up to 3 vials or 2 packs of pens) for $99 for up to 12 months.||No|
|Novolog||Co-pay card||Max $100/month savings||Yes|
|Novolog ($99 program)||My99insulin||30-day supply of a combination of Novo Nordisk insulin products (up to 3 vials or 2 packs of pens) for $99 for up to 12 months.||No|
|Novolog mix 70/30||Co-pay card||Max $100/month savings||Yes|
|Novolog mix 70/30 ($99 program)||My99insulin||No|
|Onglyza||Co-pay card||Max $150/month savings||Yes|
|Ozempic||Co-pay card||Max $150/month savings||Yes|
|Soliqua||Co-pay card||Max $800/month savings||Yes|
|Steglatro||Co-pay card||Max $583/month savings||Yes|
|Synjardy||Co-pay card||Max $150/month savings||Yes|
|Toujeo||Co-pay card||Max $600/month savings||Yes|
|Toujeo ($99 program)||Valyou program||No|
|Tradjenta||Co-pay card||Max $150/month savings||Yes|
|Tresiba||Co-pay card||Max $150/month savings||Yes|
|Tresiba ($99 program)||My99insulin||No|
|Trulicity||Co-pay card||Max $150/month savings||Yes|
|Victoza||Co-pay card||Max $100/month savings||Yes|
|Xigduo||Co-pay card||Max 378$/month savings||Yes|
|Xultophy||Co-pay card||Max $400/month savings||Yes|
First line intervention:
If that doesn’t work…
|Name of website/program||Purpose||Website Link|
|Insulin help from ADA||Provides patients with approach to calling manufacturers||https://ihttps://insulinhelp.org/nsulinhelp.org/|
|AACE Prescription Savings Directory||Provides list of programs to assist in affordability of endocrine related medications||http://prescriptionhelp.aachttp://prescriptionhelp.aace.com/e.com/|
|AADE tools for healthcare savings||Provides patient assistance programs, advice on navigating insurance and Medicare||https://www.diabeteseducator.org/practice/educator-https://www.diabeteseducator.org/practice/educator-tools/affordability-resourcestools/affordability-resources|
|Partnership for prescription assistance||helps patients without prescription drug coverage find assistance||https://wwhttps://www.pparx.org/w.pparx.org/|
|Rxassist||A comprehensive database of patient assistant programs.||http://www.rxassist.org/http://www.rxassist.org/|
|NeedyMeds||Nonprofit organization dedicated to connecting people with programs to help with medication costs and other healthcare costs.||https://www.needymeds.org/https://www.needymeds.org/|
|CR3Diabetes||Provides equipment and encouragement for people living with diabetes all over the world||https://www.cr3diabetes.org/https://www.cr3diabetes.org/|
|Insulin Pumpers Foundation||Assist patients who do not have financial resources to purchase an insulin pump on their own.||http://founhttp://foundation.insulin-pumpers.org/dation.insulin-pumpers.org/|
|Affordable Insulin Project||offers tools, resources and data can be used to help find ways of decreasing cost of insulin||http://affordableinsulinprojechttp://affordableinsulinproject.org/t.org/|
|GoodRx||is a source for the lowest local price for all insulins and antidiabetic agents.||httpshttps://www.goodrx.com/://www.goodrx.com/|
|Blinkhealth||Offers 40% discounted price and patient has to pay online and pickup insulin in any pharmacy.||https://www.blinkhealth.cohttps://www.blinkhealth.com/m/|