How much do we pay for insulin in Australia?
Usually in Australia insulin has been available in three formats:
10 mL vials
3 mL pen cartridges (“Penfill” is the name for the Novo cartridges, but the Sanofi and Lilly cartridges have the same capacity)
3 mL disposable pens
Using different formats
I started off with the vials in 1982. Initially designed for drawing up into syringes, these days they’re also used for drawing up into pump reservoirs. The Omnipod and Tandem reservoirs are filled from syringes, but the Medtronic, YpsoPump, Solo, Combo, and DANA reservoirs are often connected directly to these vials for filling.
Mind you, I usually prefer to fill my pump reservoirs from 3 mL pen cartridges. It’s always been convenient to push insulin down into the reservoir, and to push air back up into the cartridge, without having to first inject the expected volume of air into a vial. For backup injections, the cartridge can easily be dropped into a pen for an injection.
Some people use disposable pens to fill their pump reservoirs, and this can work too. However with the Novo FlexTouch pens (such as used with Fiasp) we can’t control the speed of “injection”, and this can result in a froth of “champagne bubbles” in the reservoir which we then need to consolidate and flush.
Personally if I’m using these pens to fill a pump reservoir I usually just pull the pen apart and use the 3mL cartridge just like a regular pen cartridge (they can even be put into a standard pen).
Pricing with PBS
We get a prescription from the doctor which specifies the format of the insulin, and these are almost always for the same amount (150 mL) of insulin. With U100 insulin (100 U/mL) this is 15,000 U. But depending on the format, the amount we pay can vary.
10 mL vials
With 10 mL vials we get a script with two repeats. So we can get the insulin dispensed three times. Each time we will get five vials (50 mL).
The PBS-subsidised price for each dispensing is currently $30 ($7.30 for concession) although pharmacies are allowed to discount this to $29 ($6.30). I’m going to use the discounted price in these examples. So the insulin is costing us $0.58 (or $0.13) per mL.
3 mL cartridges and pens
The dispensing rules for these are each the same. We get a script with one repeat, so we can get it dispensed twice. Each time we will get five boxes of 5x cartridges/pens (a total of 75 mL). The PBS-subsidised price is the same, so we end up paying less per mL. We pay $0.39 (or $0.08) per mL.
So for the price-conscious, the cheaper price of cartridges/pens is sometimes extra incentive for pump users to avoid the 10 mL vials.
Private scripts for PBS-supported insulins
The PBS website shows us how much they’ve negotiated to pay the supplier for the insulin (this info is sometimes printed as “full price” on the pharmacy label). So if we have a private (non-PBS) script that is the price we pay. Here’s a summary of some of them as at March 2023:
| Insulin | 5x vials | 25x pens / cartridges |
|---|---|---|
| NovoRapid Fiasp Humalog U100 |
$125.67 $2.51/mL |
$211.62 $2.82/mL |
| Apidra | $131.87 $2.64/mL |
$222.42 $2.97/mL |
| Levemir (not for pumps) | n/a | $354.92 $4.73/mL |
| Optisulin U100 (not for pumps) | n/a | $186.12 $2.48/mL |
So if you had private prescriptions for Fiasp, not only do they get a lot more expensive than with PBS, but per mL pens are more expensive than vials.
These are obviously huge jumps from $0.08 per mL! Mind you, they are still a lot cheaper than in unregulated markets like the US.
Pump users can more-easily choose based on price than MDI (injecting) users. If you end up using vials for injections, at least the syringes are still free through NDSS even though they’re less convenient than pens.
Private scripts for non-PBS-supported insulins
With Fiasp not being price-controlled by PBS after March 2023, we don’t know how much these will cost. The prices may change over time. We do expect they will start off similar to the current price levels.
Not only do we not know how long Fiasp will be available in Australia for (Novo has so far only indicated “for some time”) we have no idea what will happen to the price.
Still hoping
Hopefully PBS and Novo can get their acts back into gear and have Fiasp remain on PBS. Of course, there’s also the hope that Lilly will pull their finger out and make Lyumjev available in Australia to give us some choice.
Defintely it’s that last outcome I’m holding out hope for as a possible silver lining. Seems likely that there has been an underestimation by the PBS decision-makers on the extra utility provided by Fiasp over Novorapid, and this has led to its removal. Presumably the intention was well-meaning rather than mean-spirited, with a view to providing the greatest good to the greatest number using a limited bucket of public money – even if this position was poorly researched.
I’m guessing that once Fiasp has been removed they are unlikely to reverse this decision, but it does seem like a pretty easy way for them to respond to the backlash would be to court Lilly to bring Lyumlev to Australia (and onto the PBS of course!) The delisting of Fiasp may even make this a more viable option, by increasing the potential market for Lyumjev (perhaps there is only room for one ‘fast’ insulin in Australia, and this has what has kept Lilly away?)
As a looper I can’t help but think faster is always better (because the loop will always adjust accordingly), so my preference would be for Lyumjev over Fiasp. I do recognise though that there are many on an MDI regime who have come to rely on Fiasp, and potentially Lyumjev could be TOO fast for some, posing a risk of more frequent post-prandial lows.
Fiasp doesn’t work for everyone (some seem to have reactions to it, resulting in things like local site reactions or the overall efficacy falling away). Some people reporting stinging on infusion as well (sometimes longer cannulae can help?).
Lyumjev has its own issues with stinging (the vasodilator it uses is known for this) but for many people this is manageable.
So while I know from experience that Lyumjev is wonderful with an AID system where it can take advantage of the extra speed, I think it will be best for the community if people are able to use whichever insulin works for them. So I would like to see both Fiasp and Lyumjev available, although commercial interests usually get in the way of user benefits.
I keep thinking about your comment here about how no longer having Fiasp on the PBS might improve our chances of getting Ljumjev. I hope you are right, it makes sense and gives me some hope. However, I also keep thinking about Wookie’s comment that some HCP don’t think faster acting insulins are of value. This is makes me so uncomfortable. I am MDI and I do want faster acting insulins. I heard it described really well – it is like driving a car and when you put your foot on the brake it takes 20 mins to engage. I can manage mostly with a restrictive diet (which is fine for me) but I really appreciate having the faster acting insulin for correction doses. I would love something faster than Fiasp (quick onset and quick offset) – maybe you are right and what you mentioned is happening behinds the scenes.
Interesting – in Canada pen cartridges have always been more expensive than vials. I’ve never used them as I went straight from syringes to pump 14 years ago and skipped pens. But my mom uses them, so I’ve learned their pricing. It seems insulin pricing is a very arbitrary thing. I met a pharmacist originally from Pakistan and who used to work for either Connaught or Lilly there. He said insulin was riced at what their market would bear, which was the Canadian equivalent of about $1 per vial. In the US Lilly just made an announcement that they were going to beat Biden to the punch by reducing all their insulins to lower than the threshold the was going to set, $35 I think. The over the counter price had peaked at about $350 I believe.