Wil Dubois

Happy Saturday! Welcome to Ask D'Mine, our weekly advice column hosted by veteran type 1 and diabetes author Wil Dubois in New Mexico, who happens to have experience as a clinical diabetes specialist. This week, Wil takes a plunge into the financial side of diabetes, exploring costs and insurance coverage. Here's Wil's take on that.


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Ask DMine buttonJim, type 1 from California, writes: I need some advice please. I’ve been a type 1 diabetic since 1962 (7 years old) and have tried my best to follow the guidelines when it comes to blood testing (avg 8 times a day) and A1C. For about a month now, my doctor has been struggling with my health insurance company, United HealthCare along with OptimaRx, because they are refusing to cover my basal insulin Lantus, no doubt because of the usurious prices charged by Sanofi. But they are also refusing to substitute insulin Tresiba, which is what my doctor wants me to use in place of Lantus. I believe the insurance company wants Basaglar. Funny thing about me is that I trust my doctor more than my insurance company. I am fast running out of basal insulin and options, to which I’d like to ask a couple of questions.

First, would one of my options be to go with something like NPH insulin for a basal (currently I’m giving a shot in the morning and a shot at bedtime of what Lantus I have left)? And then basically run my diabetes from an over-the-counter standpoint, buying cheap strips and insulin (some from Amazon) while looking for a cheaper catastrophic insurance? Thank you for your help!

[email protected] D’Mine answers: Congratulations on managing your diabetes for so well for so many decades. That’s awesome! I think, as you’ve been supporting the insulin industry for over five decades, they should just give you the damn stuff for free.

But of course we both know that will never happen.

First, let me be clear: I feel your pain. Hey, diabetes is hard enough without these constant fights with insurance companies. Insurance companies that apparently think they are smarter than our doctors. I’m not sure how we got to this point, and I’m sure as hell not smart enough to figure out how we’re ever going to get back out of it. But I do know that there’s nothing “funny” about trusting your doctor more than your insurance company. You’d only be funny (in the head) if it were the other way around. This practice of pushing patients onto cheaper meds without doctor consent is known as "non-medical switching," and many are protesting it.

Now before I tackle your question about NPH, let me play the Devil’s Advocate for a moment. Why not just use the Basaglar? I mean, for all practical purposes, it is Lantus. You were on Lantus. You liked Lantus. You and your doc fought to keep the Lantus. So why the jump to Tresiba? That’s an animal of a whole different stripe altogether -- and even more expensive than Lantus, hence the insurance company’s hesitation to pay for it.

To be honest, I don’t have a problem with formularies favoring Basaglar over Lantus. Hell, we PWDs have been screaming for generic insulin for decades, and now that we finally have it, we reject it? What’s up with that?

I’d be willing to bet that if someone had slipped Basaglar into your Lantus vial, you’d never notice the difference. It really is six of one, half dozen of another. At least until it comes to the money. Sadly, the “generic” insulin isn’t as cheep as we hoped it would be, and while the rates given to insurance plans are trade secrets, clearly Lilly has undercut Sanofi, and probably by more than just a few dollars. Hell, even Basaglar’s retail price is about 15% lower than Lantus, which isn’t chump change when it comes to millions of vials purchased, especially given it’s basically the same insulin. (I do realize Basaglar only comes in pens, I was just being lyrical.)

But what I do have a problem with is a wider issue of insurance companies crying 'Basaglar for All'! Basaglar for Lantus, sure. Same thing. Basaglar for Levemir?

No. Way.

I have a big problem with that, and in fact my insurance company tried to do the same thing to me that yours is doing to you, only I use Levemir. Levemir isn’t Lantus. It works quite differently. When I tried Lantus, no matter when I took it, I had lows in the afternoon. Bad lows. Problem solved with two baby doses of Levemir, larger at night and smaller in the morning. In small doses, Levemir has a shorter run than Lantus, so it works with my “natural” afternoon lows. Recently, my insurance company tried to force me onto Basaglar and stated they wouldn’t cover Levemir until I had a six-month claim history on Basaglar—with a documented failure of the med.

So basically, they were demanding I end up in the ICU before they’d give me what I’ve used for over a decade. My endo hit the roof (where I already was) and luckily for me, she was able to force my Levemir through. But, yikes, neither of us needed that stress.

Boy. I sure got off track, didn’t I?

What I wanted to say is that I think it’s OK for an insurance company to insist on the cheaper of two virtually identical products. But only when the two are really the same, and you can’t simply say that all basal insulins are the same. If, like me, you’d been a Levemir user, Jim, I would say you need to stay in the fight. But as all indications are that they are willing to give you the generic (OK, OK, biosimilar) version of what you had for the same price—pocketing the profit for themselves, of course—what’s the harm to you? There’s no change in cost or in effectiveness of the product.

At a minimum, I think you should give it a try. And I think it would be way better for you than the alternative, which, as you pointed out is NPH.

Now, given your diabetes veteran status, I am 100% sure that you used NPH in the past. I’m also 100% sure that you must have lost some brain cells to hypos over the years to even consider going back to that stuff :) Have you forgotten the humps? The snacks? The delicate timing?

Sure, it was the best we had back in the day, but we can do so much better now. I think you’d find going back on it a miserable experience, although my edno told me that she’s written more prescriptions for NPH this year than for all other basal insulins combined. Why? Because her patients can’t afford the copays of the basal insulins that are covered by the insurance companies, including the “cheap” Basaglar.

Over-the-counter diabetes therapy. Just as you suggested. But unaffordable copays are a topic for another day.

So now you know what I think about NPH. What do I think about your notion of shifting to a catastrophic insurance plan to save money? To be honest, I don’t think you’d end up saving any money at all. It wouldn’t cover doctor’s visits, for one thing, and surely you must take other medications, as well. While it might work out on the cash flow for a few months, I think within a year, or two at the most, you’d actually be spending more money on your health, and living less healthily.

You’ve spent more than 50 years maintaining the standard of care with your diabetes. It would be a shame for you to abandon that now. 


This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

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