Will Interchangeable Insulin Be More Affordable in the US?

When the US Food and Drug Administration (FDA) approved Semglee, the first interchangeable biosimilar insulin, the agency pitched it as having the potential to be less costly than insulins currently on the market, but lack of transparency in pharmaceutical pricing has left analysts and advocates guessing whether it will indeed be a source of relief.

Semglee (Mylan Pharmaceuticals), first approved as a biosimilar in June 2020, costs about $100 a vial.

But receiving the "interchangeable designation" in July this year, the first for any insulin, now allows Semglee to be substituted for the branded Lantus (insulin glargine, Sanofi) at the pharmacy without the need for a separate prescription, the same way as generic medicines.

A spokesperson for Viatris — Mylan's parent company — told Medscape Medical News that the interchangeable, with its new labeling, will be "introduced before the end of the year," but it would not give any more details.

"Additional information, including pricing information, for interchangeable biosimilar Semglee will be provided at the time of product launch," said the spokesperson.

Even at $100 a Vial, It Is Not Cheap

Ian Devaney, a spokesman for the advocacy group T1 International, said the organization is optimistic, given that "another player has been able to enter into a space that has for so long been dominated by Eli Lilly, Novo Nordisk, and Sanofi." Increased competition "will help drive down the overall costs of insulin," Devaney told Medscape Medical News. But, he added, for many people, especially in low-income countries, Semglee's launch will have little to no impact on price.

Even at $100 a vial in the United States, "this is not an insignificant amount of money and presents a very difficult financial challenge for those dependent on insulin to survive," he said.

A current Semglee user agreed, sharing her story with Medscape Medical News via T1 International. "My son uses three to five vials of long-acting insulin per month, and I use one to three vials per month," said the woman, who prefers to remain anonymous. "If we were to lose Medicaid, we would still be paying up to $800 out of pocket monthly to survive, and that's not even counting fast-acting insulin or other supplies. While $100 a vial may be cheaper, these costs are still outrageous," she said.

The woman also noted that while new competitors are welcome, they also have been disruptive. After her doctor switched her to Semglee, she was notified that it was on back order. "It took a week to get it filled, and when it finally came in, it was in short supply," she said, noting that she and her son received one Semglee pen each, "well short of the three and five each we were expecting."

US Pricing Is All "Smoke and Mirrors"

Sara W. Koblitz, a food and drug law attorney with Hyman Phelps in Washington, DC, notes in a blog post that interchangeable Semglee will likely be awarded a year of marketing exclusivity, which will block other interchangeable competitors from entering the market during that time.

With no competition, "Mylan can price Semglee only slightly less than Lantus and still take market share, only marginally reducing costs to consumers," she writes.

Jing Luo, MD, MPH, an assistant professor of medicine at the University of Pittsburgh, Pennsylvania, who has studied insulin access and costs, said that having just one interchangeable on the market might not be enough to drive insulin costs down.

And, he told Medscape Medical News, "there's even a possibility that Semglee prices will go up, but hopefully that will not be the case."

Manufacturers like Mylan can also offer confidential discounts and rebates to pharmacy benefit managers (PBMs), health plans, and health plan sponsors (usually large companies that are self-insured) that make it difficult to assess the true cost, said David Steinberg, PharmD, director of pharmacy insights at Scripta Insights. The Wellesley, Massachusetts-based company advises self-insured employers on how to optimize pharmacy benefits.

When it comes to pricing, "it's a lot of smoke and mirrors," Steinberg told Medscape Medical News.

Steinberg also noted that some PBMs might choose to continue contracts with Sanofi that offer rebates for Lantus, leaving Semglee in a less-preferred position on a formulary, which could increase how much the patient pays at the pharmacy counter.

Medicare and Medicaid, however, can put Semglee in the top-tier preferred formulary position. Most Medicaid plans cover Semglee, but it appears that Medicare has not added coverage yet.

Does Current Pricing Predict the Future?

The currently marketed Semglee has an average wholesale price (AWP) that is one third of Lantus', and about half of what is published for Basaglar (insulin glargine, Eli Lilly), a "follow-on biologic" approved in 2015 that is similar to Lantus, Steinberg said.

The AWP is often cited by analysts when talking about costs. The AWP of the current Semglee 10-mL vial is $118.38; the Lantus 10-mL vial is $340.27, said Steinberg.

Five prefilled Semglee pens (each 3 mL) are $177.58; for Lantus, the AWP for five 3-mL pens is $510.37.

Luo said he has seen a box of Semglee pens retail between $177 and $195, compared with about $500 retail for the Lantus pens.

Currently, people with commercial insurance can get Semglee for $0-75 a month, for up to a year, using the company's savings program.

Steinberg said it's possible that Mylan could increase the list price for the interchangeable Semglee, but that move could backfire. "I think their goal initially is to get market share," he said.

After Basaglar came on the market — in late 2016 — the price of Lantus came down significantly over the next few years, according to a 2019 study by Luo's colleagues at the University of Pittsburgh.

But Basaglar has not hung on to market share, according to Scott Strumello, a person with autoimmune type 1 diabetes who tweets and blogs about insulin and other issues.

In early August, Strumello tweeted some Lilly data that showed US sales of Basaglar declined 42% in the first two quarters of 2021, compared with the same period in 2020.

Steinberg notes that the decline may have to do with rebates being given to PBMs by competitors Sanofi and Novo Nordisk. Sanofi "is very aggressive when it comes to pricing with their PBM partners," he said.

While the advocate Devaney said people with diabetes are hopeful that Semglee can break the big three manufacturers' monopoly, he added, "We don't see Semglee as something that is solving the root cause of the insulin price crisis, which is high list prices and pharmaceutical industry greed."

Alicia Ault is a Lutherville, Maryland-based freelance journalist whose work has appeared in publications including JAMA, Smithsonian.com, The New York Times, and The Washington Post. You can find her on Twitter @aliciaault.

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