Disclosures I have been caring for a very pleasant 68-year-old male with type 2 diabetes for the last 5 years. He came to me as a new patient having recently retired and moved across country to be with his wife’s family. Unfortunately, he had had a rough past and was stricken with multiple medical conditions. He has been taking 15 different medications to stabilize these conditions, including insulin lispro and detemir. Initially, his hemoglobin A1c was 7.1% and his blood glucose readings were running in the range of 130–180 mg/dL throughout the day. He was seen every 3 months and seemed to be doing okay until about a year after I started caring for him. Over the next 2 years his A1c went up to 8.0–8.5% and his blood glucose readings were 150–350 mg/dL throughout the day. He stated that he was bored being at home without any friends around and so he had decided to get a job at a local retail store. The timing of this made it more difficult for him to take his insulin and he was not checking his blood glucose as often as he used to. During one of his visits, he asked me for samples of lispro as he was running low on this and having to decrease his doses to stretch out the insulin. As I pushed further into this, I realized that he had been stretching out his insulin for the last 2 years as he was not able to afford it. He was on Medicare, a fixed income, and had gotten the job at the retail store to try and pay for all of his medications. He finally admitted that he wasn’t checking his blood glucose as often due to not being able to take correction doses, “so what was the point?” Between 2002 and 2013, the cost of insulin increased almost 200%, from $ 4.34 to $ 12.92 per unit. Patients on Medicare are the ones that suffer the most due to their inability to afford insulin. Due to the expense of these medications, patients end up in the "donut hole" (ie, the Medicare coverage gap). In 2016, once Medicare patients had spent $ 3310 on medications, they were then responsible for paying 45% of brand name and 58% of generic drug costs. This continued until they had spent $ 4850 and were considered to be in catastrophic coverage, paying a copay for the rest of the year. Most patients on Medicare are unable to afford this and either rely on samples from their physician or go without the medication. How can we help these patients? Use less expensive medications as long as it doesn’t jeopardize patient care. For example, ReliOn® neutral protamine Hagedorn insulin (regular and 70/30 vials) is available at Walmart for $ 25.00. Check if patients qualify for Medicare low-income subsidy or extra help. Patients pay no more than $ 3.30 per generic drug or $ 8.25 per brand name drug. Check if patients qualify for patient assistance programs provided by pharmaceutical companies (see Table 1). Patients will receive 12 months of their prescription free of charge. Use discount pharmacy companies. For example, GoodRx, Blink Health, and Inside Rx (see Table 2). Table 1. Qualification for assistance programs: Annual income per household. Program One person Two persons Four persons Medicare low-income subsidy $ 18,090 $ 24,360 $ 36,900 Lilly Cares (Lilly USA, LLC.)* $ 36,180 $ 47,720 $ 73,800 Cornerstones4Care® (Novo Nordisk Inc)* * Medicare Part D patients must spend at least $ 1100 on medications per calendar year to qualify, and must have applied and been denied for Medicare low-income subsidy. Table 2. Approximate cost differences between pharmacies. Insulin Estimated cash price GoodRX Blink Health Lispro 10 mL vial $ 330 $ 174 $ 174 Lispro box of pens* - $ 515–540 $ 322 Glargine box of pens* $ 380 $ 320–340 $ 218 Aspart 10 mL vial $ 320 $ 280–290 Unavailable Aspart box of pens* - $ 540–560 Unavailable Costs based on information for Sandusky, Ohio, USA. * Five pens Useful resources Hua, X, Carvalho, N, Tew, M, Huang ES2, Herman WH3, Clarke P. Expenditures and Prices of Antihyperglycemic Medications in the United States: 2002–2013. JAMA 2016; 315: 1400–1402. Full PMC text US Centers for Medicare & Medicaid Services. Costs in the coverage gap. Available at www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html. [Accessed 9 July 2017]. Novo Nordisk Inc. Cornerstones4Care® website. Available at www.cornerstones4care.com. [Accessed 21 August 2017]. Lilly USA, LLC. The Lilly Cares Foundation, Inc. ("Lilly Cares”) website. Available at www.lillycares.com. [Accessed 21 August 2017]. GoodRx, Inc. GoodRx website. Available at www.goodrx.com. [Accessed 9 July 2017]. Blink Health LLC. Blink Health website. Available at www.blinkhealth.com. [Accessed 9 July 2017].