Cost-Effective Pharmacotherapy for Patients With Diabetes

In 2025, the Inflation Reduction Act is set to help people with Medicare Part D prescription drug coverage benefit from a new $2000 out-of-pocket cap on prescription drug costs.¹ However, for some patients significantly below the poverty line, this cap may not be sufficient to support ongoing access to their diabetes medication. Additionally, patients who are not eligible for Medicare may continue to need financial assistance. With the increased cost of medicines, many patients are at risk for nonadherence, which can lead to worse glycemic management and increased microvascular and macrovascular complications from diabetes.² However, cost-effective strategies can help patients save money while optimizing their diabetes care.

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Enroll Patients in Patient Assistance Programs

Many drug companies offer patient assistance programs (PAPs) for expensive, brand-name diabetes medications. PAPs are programs provided by manufacturers through which eligible patients can receive medications at no cost. Eligibility criteria differ based on the manufacturer but generally require patients to be at or below a certain household income threshold and have Medicare or no insurance coverage. Some programs require patients to apply for and be denied low-income subsidies through Medicare before approving PAP applications. Some common diabetes medications with associated PAPs are shown in the Table.

HCI, hydrochloride; PAPs, patient assistance programs; VA, Veterans Affairs.

^aEligibility as of January 2025.

^bNew applications for brand-name dulaglutide (Trulicity) are currently not accepted, except for limited medical circumstances.

^cAt or below 400% of the federal poverty level for brand-name dulaglutide (Trulicity).

Manufacturer Savings Cards and Prescription Coupons

Many expensive brand-name medications, including glucagon-like peptide-1 (GLP-1) and GLP-1/glucose-dependent insulinotropic polypeptide receptor agonists (for example, injectable semaglutide [Ozempic; Novo Nordisk] and tirzepatide [Mounjaro; Eli Lilly and Company]), have manufacturer savings cards to help bring down out-of-pocket costs. Patients present these cards to the pharmacist, who then bills them as secondary insurance. Of note, most savings cards require patients to have commercial or private insurance, and they exclude patients who have state or federal prescription drug coverage, such as Medicaid or Medicare. Some savings card payments may count toward deductibles, depending on individual insurance plans. Alternatively, patients can use prescription coupons such as GoodRx to help bring drug costs down. It is essential to inform patients that prescription coupons are not insurance and that drug savings may vary depending on the pharmacy used.³

Prescription coupon cards are not limited to medications, however. Many of my patients struggle to afford their continuous glucose monitors (CGMs), which monitor their blood glucose levels at home. Some CGMs, such as the Dexcom CGM, offer these coupons on their website.³ For patients who do not qualify for CGMs based on insurance requirements, Dexcom also offers an OTC product called the Stelo, intended for people not taking insulin who are at least 18 years old.⁴ Patients can buy the Stelo as a one-time purchase or through a subscription plan on Dexcom’s website.⁴ For those who would like to use this long-term, investing in a subscription plan can save up to 15%. These devices are also eligible for flexible spending accounts and health savings accounts, pretax savings accounts that allow patients to set aside money for out-of-pocket health care expenses.⁵

Avoid Unnecessary Duplicate Therapy

Although this trend has declined over time, some prescribers still prescribe GLP-1 receptor agonists alongside DPP-4 inhibitor therapy. Because these medications work in a similar mechanism (with little to no additional synergistic benefit), patients are better off being on 1 of these medications only. In most cases, we opt for the GLP-1 agonist over DPP-4 inhibitors due to superior hemoglobin A1C lowering and cardiovascular benefits with most of the commonly used options (subcutaneous semaglutide, dulaglutide, and liraglutide). In contrast, DPP-4 inhibitors do not share this additional benefit.⁶

Use Combination Medications When Clinically Appropriate

One medication we use frequently in practice is empagliflozin/metformin HCl extended-release tablets (Synjardy XR; Boehringer Ingelheim) after a patient can tolerate and is stable on metformin and empagliflozin separately. One benefit is that this medication reduces pill burden and can be preferable for patients who are hesitant to add another drug to their regimen. Because empagliflozin/metformin HCl extended-release tablets contain extended-release metformin, patients may tolerate it better than the immediate-release formulation.⁶ Some medications contain 3 drugs, such as empagliflozin/linagliptin/metformin (Trijardy; Boehringer Ingelheim and Eli Lilly), 2 of which are brand-name medications (empagliflozin [Jardiance; Boehringer Ingelheim and Eli Lilly] and linagliptin [Tradjenta; Boehringer Ingelheim]). Switching to a medication like empagliflozin/linagliptin/metformin when clinically appropriate can save a patient from paying for 2 separate, expensive brand-name medications each month, potentially improving adherence and outcomes.

The use of combination drugs can also apply to common comorbidities associated with diabetes, such as hypertension. If patients can tolerate them, it may be beneficial to use combination blood pressure regimens (for example, ACE inhibitor/thiazide combinations) to aid with adherence, which can lead to better blood pressure control.

Spread Medicare Costs Out Over the Year

Starting in 2025, patients can spread their out-of-pocket drug spend into monthly payments. Members who enroll will be billed by the plan and pay $0 at the pharmacy point of sale. Patients may be a good fit for this option if they filled a prescription costing over $600 or spent more than $2000 on the Part D prescription plan in the prior plan year.⁷

To make the most of this program, counsel patients to enroll as early as possible in the year, as costs will be spread out over more months, lowering their monthly bill. Advise patients to visit their health or drug plan website or call their plan for more information.⁷

REFERENCES

1. Inflation Reduction Act and Medicare. US Department of Health and Human Services. Updated January 17, 2025. Accessed January 23, 2025. https://www.hhs.gov/inflation-reduction-act/index.html

2. Barthold D, Li J, Basu A. Patient out-of-pocket costs for type 2 diabetes medications when aging into Medicare. JAMA Netw Open. 2024;7(7):e2420724. doi:10.1001/jamanetworkopen.2024.20724

3. GoodRx. Goodrx.com. Accessed January 16, 2025. https://www.goodrx.com/

4. Dexcom Savings Center. Dexcom. Accessed January 16, 2025. https://www.dexcom.com/savings-center

5. Stelo Glucose Biosensor – one-time purchase. Stelo. 2020. Accessed January 16, 2025. https://www.stelo.com/en-us/buy-stelo-one-time

6. American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025. Diabetes Care. 2025;48(suppl 1):S181-S206. doi:10.2337/dc25-S009

7. What’s the Medicare Prescription Payment Plan? Medicare. 2024. Accessed January 16, 2025. https://www.medicare.gov/prescription-payment-plan

The author has nothing to disclose.