Comparing Insulin Prices in the United States to Other Countries: Updated Results Using 2022 Data

Manufacturers’ gross prices for insulin have increased dramatically since the early 2010s in the United States. At the same time, recent studies found flat or even decreasing U.S. trends for manufacturer net insulin prices—that is, prices reflecting off-invoice discounts paid from drug companies to insurers, their pharmacy benefit managers, and others in exchange for favorable placement on formularies.

In this study, we present results from comparisons of U.S. and international prices for insulins using a price index approach. We aim to

• describe the mix of insulin products used in the United States and other Organisation for Economic Co-operation and Development (OECD) countries
• estimate the direction and magnitude of gross and net insulin price differences between the United States and other countries
• identify trends in these price comparisons over time.

We used 2017–2022 IQVIA MIDAS data describing the national insulin markets in terms of volume and sales by product separately for the United States and 33 comparison OECD countries. We present separate comparisons using manufacturer gross prices, which may be more relevant to U.S. patients without drug coverage or otherwise paying out of pocket for insulin, and estimated manufacturer net prices after applying rebates paid by manufacturers.

Using our main price index approach, we found that U.S. manufacturer gross prices per 100 international units (IUs) of insulin were on average 971 percent (or 9.71 times) of those in OECD comparison countries combined. After estimating gross-to-net discounts for insulins, U.S. net prices remained 233 percent (or 2.33 times) of those in comparison countries combined. Related to these main results, we found the following:

• In terms of comparisons to specific countries, U.S. manufacturer gross prices ranged from 457 percent of those in Mexico to 3,799 percent of those in Turkey.
• Although the ratio of U.S. to other-country gross prices varied depending on the comparison country and insulin category, U.S. prices were always higher—often five to ten times higher—than those in other countries.
• Comparisons of U.S. insulin prices to prices in other countries were fairly constant from 2017 through 2022.

Our price comparisons were limited to insulin products sold in the United States and in comparison countries. We found generally broad overlap in the insulins used in the United States and other countries. All insulin active ingredients sold in the United States were also sold in other countries. We found nine insulin products (defined in terms of unique combinations of insulin active ingredient, dosage form, and dosage strength) sold only in the United States and 53 insulin products sold only in non-U.S. OECD comparison countries, compared with 30 insulin products sold in both the United States and comparison countries. Despite the many insulin products sold only in or outside the United States, 98 percent of U.S. spending on insulins was on products available in other countries, while 88 percent of other-country spending was on products also available in the United States.

This suggests that the United States may use a more expensive mix of insulin products. The United States was unusual among comparison countries in permitting distribution of several types of insulin over the counter, which is likely driven by access concerns. We found modest and decreasing use of over-the-counter insulin in the United States. We also found the average vial or other “standard unit” of insulin in the United States had a higher dosage strength in terms of IUs compared with other countries.

It is important to note that manufacturer gross prices, for which we found much larger relative differences between U.S. and other-country prices, are the basis for prices throughout the U.S. prescription drug supply chain, including prices paid at pharmacies. As a result, patients without drug coverage, as well as patients with drug coverage paying in a deductible phase or patients responsible for coinsurance based on a percentage of total cost rather than a fixed copay, are responsible for either all or a share of payments to pharmacies that are anchored initially on manufacturer invoice prices.

Medicare enrollees’ financial exposure to U.S. insulin gross prices and out-of-pocket spending for insulin and for all drugs are changing dramatically: Inflation Reduction Act (IRA) provisions limiting insulin cost-sharing and requiring rebates for drug price increases beyond inflation are already in effect, and total out-of-pocket spending in Medicare Part D will be capped beginning in 2024 (Pub. L. 117-169, 2022). These policies do not apply to those with coverage outside Medicare, but Congress is considering proposals to extend the IRA's $35 cap to individuals with employer or individual market coverage (Kennedy, 2023; Collins, 2023). Recent announcements from all three U.S. insulin manufacturers regarding reductions in gross prices nearer to current net prices are a more encompassing change that will have broader implications for all patients (Eli Lilly and Company, 2023; Novo Nordisk, 2023; Sanofi, 2023). Other changes in how insulin is sold—for example, the increased availability of biosimilar insulins and the recent emergence of bifurcated marketing approaches in which the same insulin is simultaneously sold by its manufacturer under a brand name (where rebates apply) and as an unbranded product (where rebates do not apply)—may also have important longer-term implications for U.S. insulin prices, how they compare with prices in other countries, and consumer out-of-pocket spending on insulin.