Drug pricing

Insulin pricing: could an e-commerce approach cut costs?

An e-commerce drug delivery approach could put a dent in upward spiraling insulin prices, but William Newton finds that uptake challenges still loom large.

Alisdair Lackie

As insulin prices continue to soar, the advent of e-commerce drug manufacturers could provide a path to cheaper insulin. But reluctance to shift from traditional prescription models–and uncertainty over a burgeoning black market for illicit insulin–could pose significant obstacles.

Recently, several high-profile companies have promised to upend the healthcare model and deliver generic drugs and biosimilars directly to consumers. Under these models, patients with or without insurance can fill the prescriptions they receive from their healthcare providers.

On 3 March, the nonprofit Civica Rx announced plans to produce and distribute low-cost insulin biosimilars to patients with diabetes. Earlier this year, Mark Cuban Cost Plus Drug Company launched an online pharmacy delivering generic drugs to consumers, which works in tandem with its own partner pharmacy benefit manager (PBM).

While experts say e-commerce approaches like these could cut insulin costs for many patients, there is skepticism they’ll be utilized enough to make a substantial difference. Most US patients use brand-name analog insulins, which are genetically modified forms of human insulin offering more glycemic control.

Biosimilars, which are interchangeable with brand-name analog insulins, are not widely available, and patients have less confident in online-purchased medications.

Still, as Covid-19 opens the door to nontraditional healthcare delivery models, a shift towards cost-saving e-commerce insulin could be on the horizon.

New technology drives changes

As telehealth shifts the geographical boundaries of the traditional healthcare model, patients could look at alternative ways to receive their medication, explains Stephen Eckel, an associate professor at the University of North Carolina’s Eschleman School of Pharmacy. This could include forgoing local pharmacies in favor of online, direct-to-consumer insulin pharmacies, he says.

Though patients seeing local providers will likely continue filling prescriptions at local pharmacies, patients with remote providers could be more receptive to exploring e-commerce insulin options, Eckel notes.

Already, the Covid-19 pandemic has catalyzed a surge in remote and telehealth features in clinical trials that could translate to real-world healthcare practice.

Because shipping conditions have become very stable in the US, insulin directly shipped to patients is as effective as insulin purchased and stored in traditional pharmacies, adds the University of Florida’s academic researcher Timothy Garrett, PhD, who has studied pharmacy insulin sales. Traditional pharmacies normally don’t buy insulin until someone needs it, so in some ways, it’s easier to ship directly to consumers who will use it right away, he adds.

In addition, an increase in wearable technologies and AI-based treatment algorithms could give patients with diabetes more direct control over medicating their disease, Eckel adds. The growing popularity of continuous glucose monitors, which allow patients to view their blood glucose levels in real-time, are placing patients at the center of their medication plan.

“If patients utilize these tools to self-manage their diabetes, then they might utilize these tools to self-medicate and explore different places to get their medication,” Eckel says.

Effect of rising prices

By shipping insulin directly to the home and eliminating the need for retail space, e-commerce insulin pharmacies and manufacturers could reduce some costs for patients, Garrett says. But pharmaceutical companies still largely drive insulin prices, meaning e-commerce approaches may only have a minimal effect without a dedicated drug manufacturer, he adds.

Recent pricing data for the analog insulins that dominate the US market paint a bleak picture of rising prices. According to GlobalData’s pricing intelligence database, the most common analog insulin brands have more than doubled their manufacturer price over the last decade. For example, Novo Nordisk’s Levemir had a list price of $135 for a 1,000 IU vial in 2013, which rose to $308 in 2022.

However, Eckel says it's escalating prices like these that could drive patients to explore alternative options like e-commerce manufacturers.

“When those market forces are in play and you have a critical lifesaving medication that patients cannot live without, there’s potential for disruption of the traditional methods for dispensing insulin,” Eckel says.

“That includes potential for new entrants to the market like generic manufacturers, and that also gives rise to alternative ways for patient to get that medication.”

One such manufacturer, Civica RX, plans to produce insulins glargine, lispro and aspart, which are interchangeable biologics with Lantus, Humalog and Novolog, respectively, as early as 2024. These insulins will have a recommended price to the consumer of no more than $30 per vial and no more than $55 for a box of five pens, says Civica chief communications officer Debbi Ford. Civica insulins will be available to any hospital, retail or online pharmacy that is willing to sell them at no more than the recommended price, she adds.

Hurdles to success

The biggest barrier to more online pharmacies is patient confidence in the product, Garrett says. Patients must continue to build trust in online communication with pharmacists in the absence of an in-person interaction, as has been the case during Covid-19, he explains.

Adding to this challenge is the prevalent black market for insulin, which poses a dangerous risk for patients ordering insulin online, Garrett notes. Incorrect insulin could mean patients lose the ability to control their blood glucose levels, potentially risking death, he explains. A 2020 JAMA meta-analysis of Craigslist ads for insulin illustrates the price difference between illegitimate online sales and manufacturer list prices.

Pharmacies normally don’t test insulin quality themselves and instead rely on US Pharmacopeia (USP) certifications of the manufacturer’s insulin, Garrett explains. A USP certification ensures that the manufacturer is producing insulin that meets US quality standards and can be prescribed to patients, he adds.

Typically, when an illegitimate manufacturer tries to circumvent the system, it falsifies analytical testing documents, Garrett says. The only way to combat black market insulin sales is to have a testing program that would randomly test some of the insulin pharmacies are selling to ensure it meets standards, he notes.

Beyond black market risks and confidence barriers in online insulin sales, moving outside traditional models of medication purchases could prove a tall order. “Most individuals that that are utilizing insulin already have a close relationship with a physician and a close relationship with a pharmacy,” Garrett says. “But things could change.”