Many Marylanders who use insulin to control their diabetes will now see some relief from the notoriously expensive price of this life-sustaining drug.
A state bill capping insulin copays at $30 for a 30-day supply for people with state-regulated commercial insurance plans went into effect Jan. 1, along with a federal law capping monthly copays at $35 for Medicare beneficiaries.
The law does not cover large employers, who fall outside the state’s regulatory power, or the uninsured. Medicaid beneficiaries already pay minimal copays for their prescriptions.
Joseline Peña-Melnyk, state delegate and lead sponsor of the Insulin Cost Reduction Act, said many constituents have contacted her over the 15 years she’s been in office “begging us to do something” about the high cost of prescription drugs. Insulin was prioritized because it is both expensive and necessary for the survival of those who use it, she said.
About 568,000 Marylanders have diabetes, and 36,000 more are diagnosed each year, though not all of these are insulin-dependent. In 2020, about 2.7 million state residents under age 65 had private health insurance and over 1 million people had Medicare.
Among privately insured people who would be affected by the new state law, over one in four pay more than $35 per month for insulin. Medicare beneficiaries with Part D prescription drug coverage pay an average of $54 per month out of pocket for insulin, though costs vary widely by brand and some of the more commonly used products cost much more.
In passing its law limiting what diabetics pay for insulin, Maryland joins at least 20 other states and Washington, D.C., that have passed similar laws, as part of a broader national trend of states attempting to regulate prescription drug prices, often in the face of legal challenges from the drug industry.
Budgeting to live
Seventy-two-year-old Rose Hobson, a resident of District Heights, has been taking insulin for her Type II diabetes since 1994 and pays $100 per month out of pocket. Hobson says the price drop is a “substantial amount of money” that will help her stay on top of other bills.
Hobson knows others pay much more for their insulin: “I’m one of the lucky ones,” she says. As a former federal employee, she has a good supplemental health plan that picks up a sizable portion of what Medicare does not cover, but her insulin copay — on top of what she pays for other medications — “does hit my budget” as a retiree living alone.
Andrew Chalk, a 30-year-old Catonsville resident and manager of a local brewery, was diagnosed with Type I diabetes as a child. His health insurance covers the total cost of both the short-acting and long-acting insulin he takes. However, he didn’t have access to health insurance before he was promoted to manager two years ago or at other jobs. Then he paid about $260 per month for a subsidized plan on the state health exchange plus $125 per month for insulin.
Chalk remembers struggling to pay for insulin, other diabetic supplies such as glucometers, test strips, and insurance, which, due to his illness, he could not go without. Insulin “definitely ate up a lot of my budget” he said, and credits “a strong support system,” with never having to ration or go without the drug. Like Hobson, Chalk knows he is lucky compared to some.
Chalk said the copay cap about to go into effect for privately insured people like him “is awesome” and would have meant less of the stress he once felt budgeting for insulin.
Still, the new law doesn’t solve all the issues diabetics face in obtaining medication, Chalk says. He’s had to suddenly switch brands of insulin when they “fall out of favor” with the insurance company, he said. One time he said he was at the pharmacy only to be told the brand of short-acting insulin he used was no longer covered. He ended up paying $100 out of pocket for one week’s supply until his doctor could change the prescription.
“It’s a comfort thing when you know you have something that works and then you have to change it,” Chalk says. “It’s stressful for a couple of weeks.”
Chalk recounts that in another instance he spent four hours on the phone trying to get his insurance company to authorize a refill two days early to have enough insulin for vacation. Another time, he left his insulin pen and glucometer on the subway in New York and had to spend over $100 at a local pharmacy to last a few days because it was too early for a refill.
While insurance carriers will shoulder the cost of reducing allowable copays, Peña-Melnyk said most of this will be offset by a reduction in other, higher costs related to treatments for complications when the disease is not properly managed. Diabetes is the leading cause of kidney failure, for example, which leads to dialysis and can only be cured by a transplant.
While negotiating, Peña-Melnyk said insurance companies “realized it wasn’t really going to create a dent in their bottom line and that it was worth it,” to cap copays, she said.
“You have to take into consideration what you’re saving from prevention,” she said, especially for costly services such as emergency room visits and hospitalizations that could be avoided through lower-cost insulin. Still, it took “a lot of work and a lot of meetings to get to a yes,” from big industry players, Peña-Melnyk said.
Peña-Melnyk insists that capping insulin copays will not drive up premiums, though fiscal analysis indicates that local government health plans and small group plans could see some “potential increase.”
Maryland’s Prescription Drug Affordability Board will now make recommendations for capping what large employers and the uninsured will pay for insulin — the last remaining segments of the state population for whom costs will not be controlled.
According to Andrew York, the board’s executive director, the body will likely recommend forging an agreement with manufacturers to obtain free insulin through already established patient assistance programs, or establishing a partnership with the safety net health care entities participating in the federal 340B program, which purchase insulin at a deeply discounted price.