FUDiabetes

This Colorado Bill Would Cap Insulin Copay's to $100 a month

Would be nice if this passes, as well as starting a wave of bills in other states.

https://leg.colorado.gov/bills/hb19-1216

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For those using novolog, you may be able to get for $25 per month, if you have insurance that covers it. (Any state, good for 2 years, not Medicare)

Other insulins may have similar cards/discounts.

I know Afrezza also has discount card, but worthless to me since not on my pharmacy formulary.

Novo savings card is not valid for Medicare. I was just at the pharmacy to pick up some Novolog and Tresiba. $580 for one box each. I guess I’m in the donut hole. I can afford it, but what about those seniors living on their $1600/mo social security check?

I respect what the Colorado legislature and governor did, but the Federal government needs to rapidly address this problem.

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Agree!

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How does this work? Who will determine what a one-month supply of insulin is?

Implementation hasn’t been figured out, it is just in the beginning phase. So, not sure. Ultimately this may fail during implementation, but it is at least some legislative action in the right direction. Honestly, the federal government needs to take action, but they aren’t doing much.

I would say much the same that it already does. Each person consumes more or less insulin than other people, but insurance caps the amount you pay each month based on your insurance. So if you need 300 vials, or 3 vials, it’s already capped. This legislation just plans to cap it at a set amount and making the pharma/insurance eat the rest of the cost. I’m sure they’ll (pharma/insurance companies) still find a way to push this down to consumers, though.

So this doesn’t change the way insurance works, it just lowers the cap? I was wondering whether insurance companies could circumvent this legislation by defining a one-month supply as a ridiculously low number of vials and then still charge current prices, claiming you bought more insulin than necessary. I guess they can’t if this is the only change.

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I’m only speculating, though, will be following it closely, though to see how it goes for them!

I’ve never had co-pays that were close to that on insurance for insulin alone—my copays tend to be about $30 for the two types of insulin I use, so $60/month, which is affordable for me but still too much for many, but wouldn’t be changed by this cap. Do many insured people have higher amounts of co-pays for the insulin alone?

The problem I ran into instead when I had crappy graduate student insurance was that my insurance plans had total prescription payout caps that were absurdly low ($1000-$2000/year), which meant after 1-3 months, I had no more prescription coverage whatsoever and had to pay out of pocket for my insulin and other meds (a couple of which were as expensive as insulin). I paid about as much for meds as I did for rent during that time, and it’s only because my parents were fortunate enough to be able to help with that (and kind enough to be willing to) that I didn’t end up in a ton of debt. This sort of cap wouldn’t help fix that kind of situation at all, nor help people who are uninsured.

I don’t believe caps are allowed for most plans anymore. The ACA defined prescription drugs as an essential health benefit (EHB). Caps are not allowed on EHBs in the individual or small group marketplace plans. I believe the same is true for employer sponsored health plans, but would need to look it up.

EHBs are also subject to the OOP max, so once the max is reached, the drugs should be fully covered by the insurance company (assuming the drugs are on the plan’s formulary).

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That makes sense, I thought the ACA might have fixed that, which is great. It was a really crappy situation, and a lot of my fellow students didn’t understand at all, because $1000-2000 caps to them seemed like so much, ha, sigh.

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Plans that use copayments as the cost-sharing mechanism generally have these caps in place (caps on a member’s cost-sharing).

Plans that use coinsurance for prescription drugs may or may not have such caps.

Based on @ClaudnDaye’s prior posts, it sounds like he has exceptionally good health insurance.

I’ve seen plans with 50% coinsurance for drugs with no maximum/month. These plans are still subject to the yearly out-of-pocket maximum defined by HHS which is around $7,000 for an individual plan. This would be a significant improvement for an individual in a plan like that one.

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Some plans have deductibles that apply to prescription drugs, so they’d provide no benefit until that level is met, which of course would add up quickly with an rx like analog insulins…

I’d like to see more progress on the list price / net price disparity, that is what is continuously driving the list price fraudulently higher… if this practice took place in any other type of transaction it would be considered fraud, eg inflated invoicing fraud —- but for some reason it’s tolerated in medical insurance

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Here is wording of bill:

The bill caps the cost sharing a covered person is required to pay for prescription insulin drugs to $100 per one-month supply of insulin.

It uses the term cost sharing, not co-pay or co-insurance. That may mean it would still cost $100 max oop, applied to deductible. (Per refill).
This is how the novolog discount card works.

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You can buy insulin from Canada significantly cheaper. Humalog is under $50 a vial at https://rxcanada4less.com/
And it’s not generic. It’s manufactured by Lily in the US and shipped to Canada. You also don’t need a current script. You can send them an old script or even a pharmacy prescription label ripped off a vial/box you already have. Once they have either of these, you don’t even have to send new documentation each year - you are good forever.
I think shipping is like $25 per shipment, so several bottles at a time is the most economical. I have always done standard shipping vs express. No issues there, but I do know they don’t ship in extreme cold or heat, so a little planning ahead is required.
They ship requiring a signature in delivery so you may have to do a “care of” if you won’t be home to sign for it. Finally, the Canadian Post Office is private. You will get an email giving you a link with appropriate delivery date, but the Canadian Post Offices are closed Saturday. If your email expects delivery on Mon, it will likely be delivered by the US post office on Saturday.

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What we need for reform is to cap the price per vial (or per unit of drug) and not a cap on co-pays. Without a cap on the actual product, Pharma still gets to charge whatever the market will bear and Insurance will get to adjust to whatever is legislated. The Colorado plan would double my cost on Humalog and would not touch my pump supplies and the other drugs I take. I would hate to have to try to emulate my pump with MDI and syringes because there’s a cap on just insulin; having long misdiagnosed LADA, insulin is just part of the therapy picture now.