A Publication of Northeast Physicians Hospital Organization  
Diabetes, High Cost of Medications and Patient Non-Adherence

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.


The actual costs for diabetes medications to health plans or NEPHO vary significantly. Low-cost animal-derived insulin products are no longer available in the U.S.and costs have risen significantly for the newer, recombinant versions of insulin. Average costs of insulin range from $0.05 per unit to $0.30 per unit.  As an example, a 30 unit daily dose of basal insulin (Lantus, Levemir) could cost $230 per month or about $2,700 per year.  Other insulins such as Novolin N / Humulin N (NPH Insulin) cost less at about $100 per month. In addition, newer oral agents such as the DPP-4 inhibitors (Januvia, Onglyza etc.) and injectable GLP-1 receptor agonists (Byetta, Victoza etc.) have monthly costs in the $200 - $400 range. (See 


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.
      2. Ask questions to identify patient non-adherence barriers such as:
  • Do you have any barriers in taking your medications?
  • In the past  few days / week how many times have you missed taking your metformin (other medications)?
  • Is cost an issue when filling your medications on time?
  • What tools do you use to help remind yourself to take your medications on time?
  • Refer patients with medication barriers to Clinical Pharmacist ([email protected] 978 236 1774)
      3. Encourage use of cost saving strategies.
  • Mail-order - saves one copay per 90 days ($40 - $240 per year.
  • Walmart, Target, CVS, Walgreens have $4/30-day or $10/90-day copay medication lists.
  • Medicare Part D Plans - shop around for a plan with low copays on specific medication as these vary significantly and may carry a high deductible (up to $320 per year)


ADA Diabetes Algorithm, Diabetes Care, Diabetolgia, 19 April 2012 

AACE Comprehensive Diabetes Algorithm, Endocrit. Pract.,2013 (19) No 2.

Comparison of Insulins and Injectable Diabetes Meds. Pharmacist's Letter/Prescriber's Letter. March 2015

Comparison of GLP-1 Agonists. Pharmacist's Letter/Prescriber's Letter. December 2014 

Visit www.nepho.org for valuable information, including: calendars, health plan information, fee schedules and more.
April  2015
      Volume 5 :  Issue 2       
In This Issue
Overview of Concussion
See the recent presentation by Dr. Timothy Kelliher, from Northeast Neurology and EMG. His discussion of an "Overview of Concussion" at the April Pediatric / Adolescent Nurse Practitioner / Physician Assistant meeting was well received.  Thanks to Melinda Adam, Directory of Rehab Services for assisting in preparation of the progrm.


New Lipid Guidelines FAQs

See the Precriber's Letter, Lipid FAQs, for answers to questions addressing 2013 American College of Cardiology (ACC) / American Heart Association (AHA) lipid guidelines such as:

Should patients
21 to <40 years of age 
receive a statin, 

What is the role of
Produced by Northeast PHO.  For more information contact: 
Carol Freedman, RPh, MAS, CGP 
Clinical Pharmacist NEPHO 
[email protected] 
Les Sebba M.D., Northeast PHO Medical Director 
[email protected]