Diabetes is a costly and highly prevalent chronic disease currently impacted by recent increases in the cost of injectables and inflated generic drug prices. Diabetes medications, part of the endocrine class and the second highest in cost to NEPHO, has had PMPM cost increases of over 20% since 2013. These cost increases may be contributing to patient non-adherence with resulting poor glycemic control.  Recent health plan data reveals an impact of cost on patient non-adherence with low Medication Possession Ratios (MPRs) (prescription fill rates of > 80 % of the time) for diabetes medications (70%) when compared to other classes of chronic medications such as hypertension (78%).  High cost diabetes medications, poor medication adherence and complicated medication regimens pose challenges for patients with diabetes and their providers.

Patient copays for commercial plans range from $25 - $60 per month for insulins and some oral agents. However, when covered by a Medicare Part D plan, the patient may be paying 20% - 40% of the total cost of medication, sometimes up to $170 - $190 per month. Medicare Part D patients could reach their donut hole by mid-year when on expensive diabetes medications and even earlier when on multiple medications.  

What can providers do to address issues with HIGH COST diabetes medications and possible impact on adherence? 

1. Simplify medication regimens when possible. (see ADA, AACE Diabetes Treatment Algorithms)

• Metformin, a first-line agent is considered LOW COST and once or twice a day.
• Second line agents and / or dual therapies:
• sulfonylureas are considered LOW COST and given once or twice daily. (glipizide is preferred in the elderly vs glyburide due to less hypoglycemia)
• DPP-4 Inhibitors, GLP-1 receptor antagonists and Insulin are considered HIGH COST.
• Three-drug combinations should be evaluated for both efficacy (HbA1C impact) and cost.
• A regimen with metformin (twice daily), glipizide (daily) and Victoza (daily) is expected to decrease HbA1C by 1.0% - 1.5% each, however the monthly copays will total $70 - $200 per month.
• If on greater than

  3 medication regimen and not at target HbA1C, consider a simple regimen of basal or NPH insulin which will be more effective and less costly.