Express Scripts won’t cover Eli Lilly’s new generic insulin
Eli Lilly’s new “authorized generic” of its pricey Humalog insulin, called Lispro, is excluded from the 2019 national list of covered drugs from pharmacy benefit manager Express Scripts.
The big picture: So much for all the fanfare when Eli Lilly unveiled the insulin last month. Lispro’s price doesn’t change net spending on the insulin, even though it is cheaper for people paying cash out of pocket, and PBMs have little incentive to cover the drug if a rebate doesn’t exist or is tiny.
Does this just give everyone just one more proof that the PBM’s – which Express Scripts is one of the top three, along with CVS’s Caremark and United Health’s Optium Rx – are more part of the problem of high Rx prices than part of the solution. Apparently Lilly is paying little to nothing in the format of rebates, discounts or KICKBACKS. The PBM industry was created as an answer to the UAW’s (Ford, GM, Chrysler, International Harvester, John Deere) new contract in the fall of 1969. They were suppose to save everyone money… back then they were < 5% of the Rx business …but..today they are involved in the pricing and paying for 90%+ of all prescriptions and larger percent of the Rx market they got.. the more that they got into “forcing” the pharmas’ to give them discounts, rebates, KICKBACKS if the pharma wanted one or more of their medications on their formulary … meaning that they would be covered without prior authorization or quantity limits. I have read where some pharmas are have to pay some 40% -50% of the wholesale price to the PBM to get their meds on a particular formulary.
Filed under: General Problems
I’ll have to look at the original article, but it seems like once again someone is going out of their way to nonsensically blame a PharmaCo (like suing Pfizer for doctors misusing their med for ESIs –tho they’ve been saying for years it should NOT be used for ESIs).
Maybe I just don’t understand the system, but …it’s Lilly’s fault that PBMs aren’t charging less for their cheaper generic, because they won’t cough up a rebate? So…the companies are supposed to pay PBMs more, essentially, for them to charge less for a less expensive drug….? Do I have this right? Wha…??
let’s assume that a bottle of Insulin was $500 and the PBM got a 10% kickback meaning that the insulin maker cleared $450… suddenly the PBM wants 50% Kickback in order to continue covering the insulin… for the pharma to net $450 on a bottle of insulin and clear $450.. .they raise the price to $900 and pay the PBM 50% kickback.. the pharma makes $450 and the PBM gets $450 on a bottle… Pharma comes out with a “generic insulin” with a price of $450 and tells the PBM that there will be NO KICKBACK and the PBM tells the pharma that your insulin is a NON COVERED MED for all the insulin rxs that the PBM’s covered pts. the only one in this equation that gets screwed is the pt … When I started working in Pharmacies mid-late 60’s There was no U100 insulin there was U-40 & u-80 and the U-40 was $0.99/vial and U-80 was $1.98/vial. Also back then.. Insulin was OTC, there was no PBM’s
True my mom used u40 and then later u80. All she had to do was go see the pharmacist to get it.
Steve,
Thank you for the explanation. Science & journal articles I grok…financial machinations & insurance arcana, not so much. What a lovely system…unless you happen to be the patient. Yet another reason for me to be really obsessive about my diet (recent test result said “pre-diabetes”…which seems wildly unfair since I also have been having major trouble with unintentional weight loss for several years now).
I tried to get some Fioricet a while back; it’s not an opiate & it’s not even a Scheduled med.* I took it for decades for migraines, & since I can’t get any other pain meds for my numerous pain issues any more, I figured what the heck. The stuff has been around since at least the 1940s (I saw an advert for it in an old Life magazine from that decade). They wanted to charge me FIVE BUCKS A PILL for it b/c it’s not on the ‘formulary.’ I’ve never bought illegal drugs, but I have read that’s around the going rate for oxycontin on the street. I really wish all PBMs & other such beings would take an immediate boat ride across the Styx.
*Fiorinal is, Fioricet not. There’s another poser your professional interpretation would be appreciated on. wtf?? They have the same active ingredient (butalbital); the only diff is, F’nal has aspirin, F’cet has tylenol. Does this make any sense to you??