[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




PRICED OUT OF A LIFESAVING DRUG: GETTING ANSWERS ON THE RISING COST OF 
                                INSULIN

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 10, 2019

                               __________

                           Serial No. 116-25
                           
                           
               [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                               __________
                               
                               
                               
                   U.S. GOVERNMENT PUBLISHING OFFICE

39-747 PDF                WASHINGTON : 2020    




                 COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
                
                
                
                
              Subcommittee on Oversight and Investigations

                        DIANA DeGETTE, Colorado
                                  Chair
JAN SCHAKOWSKY, Illinois             BRETT GUTHRIE, Kentucky
JOSEPH P. KENNEDY III,                 Ranking Member
    Massachusetts, Vice Chair        MICHAEL C. BURGESS, Texas
RAUL RUIZ, California                DAVID B. McKINLEY, West Virginia
ANN M. KUSTER, New Hampshire         H. MORGAN GRIFFITH, Virginia
KATHY CASTOR, Florida                SUSAN W. BROOKS, Indiana
JOHN P. SARBANES, Maryland           MARKWAYNE MULLIN, Oklahoma
PAUL TONKO, New York                 JEFF DUNCAN, South Carolina
YVETTE D. CLARKE, New York           GREG WALDEN, Oregon (ex officio)
SCOTT H. PETERS, California
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
    
    
    
    
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     2
    Prepared statement...........................................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     6
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     7
    Prepared statement...........................................     8
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     9
    Prepared statement...........................................    11

                               Witnesses

Michael B. Mason, Senior Vice President, Lilly Connected Care and 
  Insulins Global Business Unit, Eli Lilly and Company...........    12
    Prepared statement...........................................    15
    Answers to submitted questions...............................   129
Douglas J. Langa, Executive Vice President, North America 
  Operations, and President of Novo Nordisk Inc..................    31
    Prepared statement...........................................    33
    Answers to submitted questions...............................   147
Kathleen W. Tregoning, Executive Vice President for External 
  Affairs, Sanofi................................................    43
    Prepared statement...........................................    45
    Answers to submitted questions...............................   158
Thomas M. Moriarty, Executive Vice President, Chief Policy and 
  External Affairs Officer and General Counsel, CVS Health.......    58
    Prepared statement...........................................    60
    Answers to submitted questions...............................   181
Amy Bicker, R.Ph., Senior Vice President, Supply Chain, Express 
  Scripts........................................................    62
    Prepared statement...........................................    64
    Answers to submitted questions...............................   191
Sumit Dutta, M.D., Senior Vice President and Chief Medical 
  Officer, Optumrx...............................................    78
    Prepared statement...........................................    80
    Answers to submitted questions...............................   202

                           Submitted Material

Article of November 16, 2018, ``Protesters at Sanofi in Cambridge 
  decry high price of insulin,'' The Boston Globe, by Allison 
  Hagan, submitted by Mr. Kennedy................................   126
  
  
  

 
PRICED OUT OF A LIFESAVING DRUG: GETTING ANSWERS ON THE RISING COST OF 
                                INSULIN

                              ----------                              


                       WEDNESDAY, APRIL 10, 2019

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 11:49 a.m., in 
room 2322 Rayburn House Office Building, Hon. Diana DeGette 
(chair of the subcommittee) presiding.
    Members present: Representatives DeGette, Schakowsky, 
Kennedy, Ruiz, Kuster, Castor, Sarbanes, Tonko, Clarke, Peters, 
Pallone (ex officio), Guthrie (subcommittee ranking member), 
Burgess, McKinley, Griffith, Brooks, Mullin, and Walden (ex 
officio).
    Also present: Representatives Barragan, Soto, Carter, and 
Bucshon.
    Staff present: Kevin Barstow, Chief Oversight Counsel; 
Jesseca Boyer, Professional Staff Member; Jeffrey C. Carroll, 
Staff Director; Waverly Gordon, Deputy Chief Counsel; Tiffany 
Guarascio, Deputy Staff Director; Judy Harvey, Counsel; Chris 
Knauer, Oversight Staff Director; Jourdan Lewis, Policy 
Analyst; Kevin McAloon, Professional Staff Member; C. J. Young, 
Press Secretary; Jennifer Barblan, Minority Chief Counsel, 
Oversight and Investigations; Mike Bloomquist, Minority Staff 
Director; Margaret Tucker Fogarty, Minority Staff Assistant; 
Theresa Gambo, Minority Human Resources/Office Administrator; 
Brittany Havens, Minority Professional Staff, Oversight and 
Investigations; Ryan Long, Minority Deputy Staff Director; and 
Natalie Sohn, Minority Counsel, Oversight and Investigations.
    Ms. DeGette. The Subcommittee on Oversight and 
Investigations hearing will now come to order. Today, the 
Subcommittee on Oversight and Investigations is holding a 
hearing entitled, ``Priced out of a Lifesaving Drug: Getting 
Answers on the Rising Cost of Insulin.'' This is the second 
part of a hearing examining insulin affordability and ensuing 
financial and health challenges, and effects on patient lives. 
The Chair now recognizes herself for the purposes of an opening 
statement.

 OPENING STATEMENT OF HON. DIANA DeGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    With seven and a half million Americans relying on insulin, 
this problem that we are addressing today has affected 
countless lives. That is why this committee is determined to 
find answers and to find solutions. As the committee is well 
aware, despite the fact that insulin has been around now for 
almost 100 years, it has become outrageously expensive. For 
instance, the price of insulin has doubled since 2012, after 
nearly tripling in the past 10 years.
    We have all heard stories of what happens when patients 
can't afford their insulin. People have to forego paying their 
bills, or ration their doses, or skip doses altogether. I had a 
listening session in my district a couple of weeks ago and 
there was a woman who came named Sierra. Sierra has been 
struggling for over a year and a half to pay for her insulin. 
Even after rationing her insulin, she is still paying over $700 
a month. It is simply unacceptable that anyone in this country 
cannot access the very drug that their lives depend on all 
because of the price of insulin has gotten out of control.
    As the cochair of the Congressional Diabetes Caucus, this 
issue is personal with me. Along with cochair, Congressman Tom 
Reed, we examined these issues last year and we issued a report 
exposing some of the underlying problems in the insulin market. 
We put that report into the record at last week's hearing. What 
we found during our investigation was a system with perverse 
payment incentives and a complete lack of transparency in 
pricing.
    Then last week as I said, the subcommittee held its first 
hearing on this issue in the new Congress. We heard testimony 
from expert witnesses and patients in the diabetes space, and 
their message was clear. Insulin is unequivocally a lifesaving 
drug, but because of a convoluted system it has become more and 
more expensive to the point where far too many can no longer 
afford it, even though their very lives depend on it.
    We heard from Gail DeVore, who is a native of my hometown 
of Denver, Colorado, who lives with type 1 diabetes. Ms. DeVore 
described to the committee how the price of her insulin has 
shot up, and she has to ration her doses against the advice of 
her doctor. We also heard from Dr. Alvin Powers on behalf of 
the Endocrine Society who testified, ``It is difficult to 
understand how a drug that has remained unchanged for almost 
two decades continues to skyrocket in price.''
    The subcommittee also received testimony last week from Dr. 
William Cefalu on behalf of the American Diabetes Association. 
Dr. Cefalu spoke about the national survey the ADA conducted 
which found that over a quarter of the people they contacted 
had to make changes to their purchase of insulin due to cost; 
and those people had higher rates of adverse health effects. 
The witnesses last week had many different stories about the 
effects of rising insulin prices, but one consistent theme that 
emerged was the system is convoluted, opaque, and no longer 
serves the patients' best interest.
    The witnesses were some of the leading experts on diabetes 
care, and yet they couldn't point to a reasonable explanation 
for why these prices have gotten so high and that is what leads 
us here today. We have representatives from the three drug 
companies that manufacture insulin, as well as three of the 
largest pharmacy benefit managers or PBMs. Together, these 
companies are the ones that produce this drug, negotiate its 
price, and make decisions that have consequences for the 
availability and affordability of insulin for millions of 
Americans.
    I want to thank all of the representatives for coming 
today. I know for some of you, you had to change schedules, you 
had to make some adjustments and I appreciate it, because all 
of your companies play a large role in the supply chain of 
critical drugs, and all the companies have as you know received 
a lot of criticism.
    But we are not interested in just finger pointing or 
passing the buck. We are interested in finding a solution to 
this problem, and that is why we put everybody here together on 
one panel so you can help us identify what the problem is and 
how we can fix it, and again, it is not my intention, and I 
think Mr. Guthrie agrees, it is not our intention to unjustly 
assign blame to any one player. Instead, what I think is that 
many entities share the blame for a system that has grown up 
and we need a frank discussion about what is causing the 
increases and what we can do to bring them under control.
    As Ms. DeVore testified last week, ``The relief we need is 
right now, not next week, not next year. We need answers today 
because the price of insulin has risen too far, and too many 
people are suffering and even risking death.''
    [The prepared statement of Ms. DeGette follows:]

                Prepared Statement of Hon. Diana DeGette

    Today, the Subcommittee holds its second hearing on the 
rising price of insulin. With seven and a half million 
Americans relying on insulin, this problem has affected 
countless lives. That is why this Committee is determined to 
find answers and find solutions.
    As this Committee is well aware, despite the fact that 
insulin has been around for decades, it recently has become 
outrageously expensive. For instance, the price of insulin has 
doubled since 2012, after nearly tripling in the previous 10 
years.
    We have all heard the stories of what happens when patients 
cannot afford their insulin. People have to forego paying their 
bills, or ration their doses, or skip doses altogether.
    I heard from a woman in my district, Sierra, who has been 
struggling over the past year and a half to pay for her 
insulin. Even after rationing her insulin, she's still paying 
over $700 a month.
    It is simply unacceptable that anyone in this country 
cannot access the drug their very lives depend on. All because 
the price of this drug--a drug that is nearly 100 years old--
has gotten out of control.
    As the Cochair of the Diabetes Caucus, this issue is 
personal for me. Along with my Cochair Congressman Tom Reed, we 
looked into these issues last year, and issued a report 
exposing some of the underlying problems in the insulin market. 
What we found was a system with perverse payment incentives, 
and a lack of transparency in pricing.
    Then last week, the Subcommittee held its first hearing on 
this issue in the new Congress. We heard testimony from expert 
witnesses and patient advocates in the diabetes space, and 
their message was clear: insulin is unequivocally a lifesaving 
drug, but because of a convoluted system, it has become more 
and more expensive--to the point where far too many can no 
longer afford it.
    We heard from Gail DeVore, a native of Denver, Colorado, 
who is living with diabetes. Ms. DeVore described to the 
Committee how the price of her insulin has shot up, and she has 
to ration her doses, against the advice of her doctor.
    We also heard from Dr. Alvin Powers, on behalf of the 
Endocrine Society, who testified quote, ``It is difficult to 
understand how a drug that has remained unchanged for almost 
two decades continues to skyrocket in price.''
    The Subcommittee also received testimony last week from Dr. 
William Cefalu on behalf of the American Diabetes Association. 
Dr. Cefalu spoke about the national survey the ADA conducted, 
which found that over a quarter of those who responded had to 
make changes to their purchase of insulin due to cost--and 
those people had higher rates of adverse health effects.
    The witnesses last week had many different stories about 
the effects of rising insulin prices. But one consistent theme 
that emerged from them was that the system is convoluted, 
opaque, and no longer serves the patient's best interests. 
These witnesses were some of the nation's leading experts on 
diabetes care, and yet they could not point to a reasonable 
explanation for why these prices have gotten so high.
    And that is what leads us here today. We have 
representatives from the three drug companies that manufacture 
insulin, as well as three of the largest Pharmacy Benefit 
Managers ("PBMs"). Together, these companies are the ones that 
produce this drug, negotiate its price, and make decisions that 
have consequences for the availability and affordability of 
insulin for millions of Americans.
    These companies play a large role in the supply chain of 
these critical drugs, and as such, they have received a lot of 
criticism in recent years for these price hikes. We will have 
questions for the witnesses today about these increases, and 
what could possibly justify such dramatic spikes. Today is an 
opportunity for them to shed light on the true causes of these 
price increases.
    Now, this Committee is not interested in mere finger-
pointing and passing the buck. Each of these companies before 
us today has a role in this problem, and that means they must 
also have a role in identifying solutions.
    Likewise, our intention here today is not to unjustly 
assign blame to any one player--because it is clear that many 
entities share in the responsibility.
    We need a frank discussion today about what is causing 
these increases, and what these companies can do to bring them 
under control. As Ms. DeVore testified last week, quote, ``The 
relief we need is right now. Not next week. Or next year." We 
need answers today--because the price of insulin has risen far 
enough, and too many people are suffering.
    I thank the witnesses for appearing before us today, and I 
urge them all to be candid and forthcoming in their discussion 
of this very important topic.

    Ms. DeGette. Thank you all again for being here today. I 
urge you to be candid and forthcoming, and I am now very 
pleased to recognize the Ranking Member Mr. Guthrie, for 5 
minutes for purposes of an opening statement.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEATH OF KENTUCKY

    Mr. Guthrie. Thank you, Chair DeGette, for bringing this 
hearing together, and thank you all for being here. I do echo 
the remarks that you just made.
    Last week, we held a hearing on the rising cost of insulin 
and heard from patients, doctors, and patient groups of how the 
rising cost of insulin has affected Americans with diabetes. 
More than 30 million individuals--and I have two nieces--9.4 
percent of the population in the United States have diabetes. 
In 2016, about 6.7 million Americans age 18 and older used 
insulin.
    The insulin prescribed today is different than the insulin 
discovered over 100 years ago and the life expectancy of 
diabetics has improved dramatically. These innovations should 
not be underestimated and a lot of exciting research is on the 
horizon. Someday soon, I hope we will have a cure for diabetes. 
As we discussed last week, however, the average list price of 
insulin nearly tripled between 2002 and 2013, making this vital 
drug unaffordable for too many Americans.
    Many argue that while list prices have been increasing, net 
prices have stayed relatively the same or have even gone down. 
This sounds great, because in theory no one is supposed to pay 
the list price for insulin. However, if a patient is uninsured 
or underinsured, they may end up paying the list price or close 
to it. We have also heard that more Americans are paying the 
list price at the pharmacy counter for part of the year because 
the enrollment in high-deductible health plans has increased. 
We have struggled to fully understand--and I will emphasize 
this--fully understand while list prices for medicine such as 
insulin have continued to rise, the prescription drug supply 
chain is complex and lacks transparency.
    We have had a lot of conversations with participants in the 
drug supply chain over the last two years to better understand 
how the pricing and rebating system works. We have been told 
that manufacturers set the list price and therefore lowering 
the cost of prescription drugs is as simple as manufacturers 
lowering their list prices. On the other hand, we have heard 
that manufacturers can't simply lower their list price because 
the pharmacy benefit managers or PBMs demand larger rebates, 
and if the manufacturers do not provide them with these rebates 
the PBMs won't put their drugs on their formularies for health 
insurance plans.
    Although they are not on the panel today, we have also 
heard concerns about other entities in supply chains such as 
health insurance companies. As Chair DeGette said and I will 
emphasize, we are not here to point fingers at that, that is 
what we have heard. We want to try to get to a solution. While 
some may think that one party in the supply chain is solely 
responsible for the rising price of drugs, there are incentives 
to increase list prices throughout the drug supply chain. 
Beyond the potential for manufacturers to make more money by 
raising prices, a higher list price allows manufacturers to 
provide larger rebates to PBMs, most of whom have contracts 
that allow them to keep a percentage of the list price, or 
receive fees based on the list price. Additionally, the health 
insurance companies decide whether to pass the rebate along to 
the patient at the point of sale or keep the rebate to lower 
premiums across the board for all beneficiaries.
    The current system contains many incentives for list prices 
to increase rather than decrease. Unfortunately, while we keep 
hearing assurances that net prices are staying flat or 
decreasing and that almost all rebates are passed on to the 
health plans; we know that many patients are being 
disadvantaged by this system and are paying more for their 
insulin at the pharmacy counter. Your companies have taken 
steps to try to reduce out-of-pocket expenses for insulin to 
the patients who need them and that is a good thing. I worry, 
however, that these are only short-term solutions. It is 
important that we collectively find a permanent solution that 
improves access to and affordability of medicine such as 
insulin.
    I thank our witnesses for being here today and I will yield 
the remainder of my time to my friend from Indiana, Mrs. 
Brooks.
    Mrs. Brooks. Thank you, Ranking Member Guthrie and thank 
you to the subcommittee chairwoman for hosting this hearing, 
for holding this hearing. It is continuing the important work 
that was started last Congress in examining the impact that 
rising costs of insulin has on patients struggling to afford 
this lifesaving drug. Nearly 700,000 Hoosiers have diabetes or 
pre-diabetes, which is why I serve as the vice chair of the 
Congressional Diabetes Caucus founded by Diana DeGette and Tom 
Reed. We have always worked in a bipartisan manner in that 
caucus and I hope that we continue in that same spirit today to 
find solutions.
    One of the companies here today, Eli Lilly, has been 
headquartered in Indianapolis for more than 100 years. They 
employ thousands of hardworking Hoosiers, many of whom are my 
constituents. While I know that Lilly has put in place programs 
to subsidize the cost of insulin for some--and I have read all 
of your written testimony and everyone has ideas, and everyone 
has recommendations and that is what we need to get to today.
    I look forward to hearing from our witnesses on their 
recommendations for change, so that no American has to do 
without insulin or take less insulin than what they must have 
to stay alive and remain healthy. I thank you all for being 
here and I yield back.
    Mr. Guthrie. I yield back.

    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Thank you, Chair DeGette, for holding this important 
hearing.
    Last week we held a hearing on the rising cost of insulin 
and heard from patients, doctors, and patient groups about how 
the rising cost of insulin has affected Americans with 
diabetes. More than 30 million individuals--or 9.4 percent of 
the population--in the United States have diabetes and, in 
2016, about 6.7 million Americans aged 18 and older used 
insulin.
    The insulin prescribed today is different than the insulin 
discovered over 100 years ago and the life expectancy of 
diabetics has improved dramatically. These innovations should 
not be underestimated, and a lot of exciting research is on the 
horizon. Someday soon, I hope we have a cure for diabetes.
    As we discussed last week, however, the average list price 
of insulin nearly tripled between 2002 and 2013, making this 
vital drug unaffordable for too many Americans. Many argue that 
while list prices have been increasing, net prices have stayed 
relatively the same or have even gone down. This sounds great 
because in theory no one is supposed to pay the list price for 
insulin. However, if a patient is uninsured or underinsured 
they may end up paying the list price, or close to it. We've 
also heard that more Americans are paying the list price at the 
pharmacy counter for part of the year because enrollment in 
high deductible health plans has increased.
    We have struggled to fully understand why list prices for 
medicines such as insulin have continued to rise. The 
prescription drug supply chain is complex and lacks 
transparency. We have had a lot of conversations with 
participants in the drug supply chain over the last two years 
to better understand how the pricing and rebating system works. 
We've been told that manufacturers set the list price and 
therefore lowering the cost of prescription drugs is as simple 
as the manufacturers lowering their list prices. On the other 
hand, we've heard that manufacturers can't simply lower their 
list price because the pharmacy benefit managers or PBMs demand 
large rebates and if the manufacturers do not provide them with 
these rebates, the PBMs won't put their drugs on formularies 
for health insurance plans. Although they're not on the panel 
today, we've also heard concerns about other entities in the 
supply chain such as health insurance companies.
    While some may think that one party in the supply chain is 
solely responsible for the rising price of drugs, there are 
incentives to increase list prices throughout the drug supply 
chain beyond the potential for manufacturers to make more money 
by raising prices. A higher list price allows manufacturers to 
provide a larger rebate to PBMs, most of whom have contracts 
that allow them to keep a percentage of the list price or 
receive fees based on the list price. Additionally, the health 
insurance companies decide whether to pass the rebate along to 
the patient at the point-of-sale or keep the rebate to help 
lower premiums across the board for all beneficiaries. The 
current system contains many incentives for list prices to 
increase, rather than decrease.
    Unfortunately, while we keep hearing assurances that net 
prices are staying flat or decreasing and that almost all 
rebates are passed on to the health plans, we know that many 
patients are being disadvantaged by this system and are paying 
more for their insulin at the pharmacy counter.
    Your companies have each taken steps to try to reduce out-
of-pocket expenses for insulin to the patients who need them, 
and that is a good thing. I worry, however, that these are only 
short-term solutions. It is important that we collectively find 
a permanent solution that improves access to and affordability 
of medicines, such as insulin.
    I thank our witnesses for being here today. I yield back.
    Ms. DeGette. We are just waiting for the Chair of the full 
committee and the ranking member for their opening statements. 
We will just wait one moment.
    As soon as he is ready, the Chair will recognize the 
ranking member of the full committee for purposes of an opening 
statement, 5 minutes.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Thank you, Madam Chair. I appreciate your 
indulgence. I know we are all coming back from votes and a few 
things, so I am glad you are having this important hearing 
today. It is really important.
    Last week, we heard a lot of different opinions on why the 
list price of insulin has increased significantly over the last 
decade. One of the doctors on that panel commented she believed 
that high list prices primarily benefit pharmaceutical 
companies. Now another doctor argued the current rebating 
system encourages high list prices, and as the list prices 
increase intermediaries in the supply chain benefit. He argued 
the solution is not as easy as manufacturers simply lowering 
their list price, it requires a broader reform across the 
entire supply chain.
    Now all of the witnesses last week agreed that the current 
pricing system for insulin is actually harming many patients as 
they make healthcare decisions. We heard stories of individuals 
rationing their insulin and foregoing other necessities to make 
ends meet and how this can lead to serious short- and long-term 
health problems and hospitalization, which I am sure you all 
understand. It is critical we work toward ensuring that all 
diabetics have access to insulin. To do so, we need to identify 
and break through barriers that make it challenging to bringing 
down the cost of insulin for patients.
    For more than two years, we have been examining the various 
drivers of increased healthcare costs, so I am glad that effort 
is continuing today. Earlier this year, as part of this work, 
myself, and Republican leaders Guthrie and Burgess, sent a 
letter to each of you that asked specific questions about the 
cost of insulin and the barriers to competition in the insulin 
market. We wanted to learn more about what is really going on, 
so I want to thank each of you for your thorough responses to 
our questions. They are most helpful as we work on this issue.
    While the discussion today is centered around the cost and 
the barriers that exist to reducing costs, it is important we 
do not forget the critical role that both of you, the drug 
manufacturers and the pharmacy benefit managers, PBMs, have in 
making sure patients have access to lifesaving medicines such 
as insulin. Now the insulin that is available today for 
diabetics would not exist without significant investments that 
Eli Lilly, Novo Nordisk, and Sanofi have made to develop and 
improve these medicines. These investments have saved the lives 
of many diabetics. Insulin manufacturers have also created 
Patient Assistance Programs to help patients get access to 
affordable insulin.
    While there will be questions today about whether the 
changes in insulin over the past few decades justify how much 
the list price for insulin has increased over the same period, 
we know that manufacturers rarely receive the list price for 
their medicine. Likewise, PBMs provide many important services 
to patients and use different tools to help control costs while 
promotinghealthcare. For example, in addition to numerous other 
programs, CVS Health created a Transform Diabetes Care Program 
that uses several cost containment and clinical strategies to 
help produce savings. OptumRx created a tool to improve 
provider visibility to lower costs, clinically equivalent 
alternative medicines at the point of prescribing. Just last 
week, Express Scripts announced a new patient assurance program 
that will ensure eligible people with diabetes participating in 
Express Scripts plans pay no more than $25 for a 30-day supply 
of insulin.
    Now while these programs for manufacturers and PBMs are 
important and useful in the short-term, they are only a band-
aid, so we have to work on the long-term and comprehensive 
solutions. Many of the concerns we heard at last week's hearing 
on insulin are very similar to the issues that were discussed 
at our hearing examining the prescription drug supply chain 
over a year ago, so I appreciate hearing directly from the 
manufacturers and the PBMs today about your perspectives on why 
insulin costs are rising.
    But just like we heard at the hearing on drug pricing in 
2017, to fully understand why the cost of insulin is increasing 
for many patients, we will need to hear from the other 
participants in the supply chain including: the distributors, 
health insurance plans, and pharmacists. But at the end of the 
day, we have to put the patient, the consumer, first in 
everything that we do.
    I want to thank our witnesses for responding to our 
questions and I want to thank you for being here today. You 
will contribute to our work and that is most valuable, and 
unless somebody else wants the remainder of my time, Madam 
Chair, I would yield back.

    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    I am glad we are having this important hearing today. Thank 
you, Chair DeGette, for holding it.
    Last week, we heard a lot of different opinions on why the 
list price of insulin has increased significantly over the past 
decade. One of the doctors on the panel commented that she 
believed that high list prices primarily benefit the 
pharmaceutical companies. Another doctor argued that the 
current rebating system encourages high list prices and, as the 
list prices increase, intermediaries in the supply chain 
benefit. He argued that the solution is not as easy as 
manufacturers simply lowering their list price and requires a 
broader reform across the entire supply chain.
    All of the witnesses last week agreed that the current 
pricing system for insulin is harming many patients as they 
makehealthcare decisions. We heard stories of individuals 
rationing their insulin and forgoing other necessities to make 
ends meet--and how this can lead to serious short- and long-
term health problems and hospitalizations.
    It is critical that we work towards ensuring all diabetics 
have access to insulin. To do so, we need to identify and break 
through barriers that make it challenging to bring down the 
cost of insulin for patients.
    For more than two years, we have been examining the various 
drivers of increasing healthcare costs. Earlier this year, as 
part of this work, myself and Republican Leaders Guthrie and 
Burgess sent a letter to each of you asking specific questions 
about the cost of insulin and the barriers to competition in 
the insulin market. I want to thank each of you for your 
thorough responses to our questions.
    While the discussion today is centered around cost and the 
barriers that exist to reducing cost, it is important we don't 
forget the critical role that both of you--the drug 
manufacturers and pharmacy benefit managers (PBMs)--have in 
making sure patients have access to life-saving medicines such 
as insulin.
    The insulin available today for diabetics would not exist 
without the significant investments that Eli Lilly, Novo 
Nordisk, and Sanofi have made to develop and improve the 
medicine. These investments have saved the lives of many 
diabetics. Insulin manufacturers have also have created patient 
assistance programs to help patients get access to affordable 
insulin. While there will be questions today about whether the 
changes in insulin over the past few decades justify how much 
the list price for insulin has increased over the same period, 
we know that manufacturers rarely receive the list price of 
their medicine.
    Likewise, PBMs provide many important services to patients 
and use different tools to help control costs while promoting 
better health. For example, in addition to numerous other 
programs, CVS Health created a Transform Diabetes Care Program 
that uses several cost containment and clinical strategies to 
help produce savings. OptumRx created a tool to improve 
provider visibility to lower-cost, clinically-equivalent 
alternative medicines at the point of prescribing. Just last 
week, Express Scripts announced a new patient assurance program 
that will ensure eligible people with diabetes participating in 
Express Scripts plans pay no more than $25 for a 30-day supply 
of insulin.
    While these programs from manufacturers and PBMs are 
important and useful in the short-term, they are only a band-
aid. We must work on a long-term, comprehensive solution.
    Many of the concerns we heard at last week's hearing on 
insulin are very similar to the issues that were discussed at 
our hearing examining the prescription drug supply chain over a 
year ago. I appreciate hearing directly from the manufacturers 
and PBMs today about their perspectives on rising insulin 
costs. But just like we heard at the hearing on drug pricing in 
2017, to fully understand why the cost of insulin is increasing 
for many patients, we will need to hear from the other 
participants in the supply chain, including the distributors, 
health insurance plans, and pharmacists. But at the end of the 
day, we must put the patient first.
    I thank the witnesses for being here and I look forward to 
today's important discussion.

    Ms. DeGette. I thank the gentleman. The Chair now 
recognizes the chairman of the full committee, Mr. Pallone, for 
5 minutes for purposes of an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Madam Chair.
    Today, the committee is holding the second of a two-part 
hearing on the increasing price for insulin. Millions of 
Americans rely on this lifesaving drug and they are directly 
affected by the ever-increasing prices. People are having to 
make sacrifices to be able to pay for their insulin and some 
are even forced to go without it, sometimes with tragic 
consequences.
    Last week, the subcommittee heard from expert witnesses in 
diabetes care. They provided testimony about the rising price 
of various insulin medications and the effects it is having on 
patients living with diabetes. We heard from an endocrinologist 
who described a complicated system that makes it difficult if 
not impossible for him to determine how much his patients will 
have to pay for their insulin. We heard from patient advocates 
who described the hardship patients endure when they can no 
longer afford their medication or are forced to switch.
    These witnesses described a broken system where there is 
not enough transparency surrounding prices and not enough 
incentives to keep prices down. Today we have before us the 
companies that make these drugs, negotiate their prices, and 
make them available through health plans. Their actions and 
decisions have a profound impact on the lives of everyday 
Americans, and we need to hear these companies' response to the 
criticism we heard last week, and their actions, and what their 
actions are doing to contribute to rising prices or hopefully 
reduced prices.
    We know that companies need to make money in order to 
succeed and in a normal market price would reflect what the 
market can bear. The problem is, the market for insulin is made 
up of people who can't survive without the product. I am 
concerned that the market is simply broken down, as I said. It 
appears there is a limited competition and little incentive to 
keep prices at a level the patients can afford and perhaps 
there are incentives in place to keep raising prices.
    As a result, we are left with a drug that has been 
available for nearly 100 years and yet the price tripled and 
then doubled in just the last couple decades. Clearly, 
something is not right here. Three companies currently 
manufacture insulin and they are all represented at the hearing 
today. They not only make the drug, but they also set the list 
price. While most people do not end up paying this list price, 
uninsured patients often do, and even insured patients can be 
affected when the list price rises, and that is exactly what 
has been happening as the list price has skyrocketed in recent 
years and it ripples through the entire system.
    We also have the pharmacy benefit managers or PBMs here 
whose role it is to negotiate lower drug prices on behalf of 
the insurance plans. But there is not much transparency in 
these negotiations and there are questions as to whether 
discounts are being passed down to the patient. When the 
manufacturers have been criticized for raising their prices, 
they have often pointed their finger at the PBMs. When the PBMs 
have been questioned about their practices, they often point 
their finger back at the manufacturer and so we are left with 
no accountability.
    For the millions of people who are suffering in the system, 
these back-and-forth arguments are frustrating and frankly 
unacceptable. Everyone seems to be coming out ahead here except 
the patient, and no one really should suffer because the high 
price of insulin puts it out of reach. I hope that we can all 
learn today about why the costs of insulin are skyrocketing, 
and the role of manufacturers, and PBMs have played, and then 
figure out how to deal with it so we can make insulin more 
affordable.
    So unless somebody else wants my time, Madam Chair, I will 
yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today the Committee is holding the second of a two-part 
hearing on the increasing price for insulin. Millions of 
Americans rely on this lifesaving drug, and they are directly 
affected by the ever-increasing prices.
    People are having to make sacrifices to be able to pay for 
their insulin, and some are even forced to go without it--
sometimes with tragic consequences.
    Last week, this Subcommittee heard from expert witnesses in 
diabetes care. They provided testimony about the rising price 
of various insulin medications, and the effects it is having on 
patients living with diabetes.
    We heard from an endocrinologist who described a 
complicated system that makes it difficult--if not impossible--
for him to determine how much his patients will have to pay for 
their insulin.
    We heard from patient advocates who described the hardship 
patients endure when they can no longer afford their medication 
or are forced to switch.
    These witnesses described a broken system, where there is 
not enough transparency surrounding prices, and not enough 
incentives to keep prices down.
    Today, we have before us the companies that make these 
drugs, negotiate their prices, and make them available through 
health plans. Their actions and decisions have a profound 
impact on the lives of everyday Americans, and we need to hear 
these companies' response to the criticism we heard last week, 
that their actions are contributing to these rising prices.
    We know that companies need to make money in order to 
succeed, and in a normal market, prices would reflect what the 
market can bear. The problem is, the market for insulin is made 
up of people who cannot survive without this product.
    I'm concerned that the market has simply broken down. It 
appears that there is limited competition and little incentive 
to keep prices at a level that patients can afford, and perhaps 
there are incentives in place to keep raising prices.
    As a result, we are left with a drug that has been 
available for nearly 100 years, and yet the price tripled and 
then doubled in just the last couple decades. Clearly, 
something is not right here.
    Three companies currently manufacture insulin, and they are 
all represented at this hearing today.They not only make the 
drug, but they also set the ``list price." While most people do 
not end up paying this list price, uninsured patients often 
do--and even insured patients can be affected when the list 
price rises.
    That is exactly what has been happening, as the list price 
for insulin has skyrocketed in recent years it ripples through 
the entire system.
    We also have the Pharmacy Benefit Managers or "PBMs," here, 
whose role it is to negotiate lower drug prices on behalf of 
the insurance plans. But there is not much transparency in 
these negotiations, and there are questions as to whether 
discounts are being passed down to the patient.
    When the manufacturers have been criticized for raising 
their prices, they have often pointed their finger at the PBMs, 
and when the PBMs have been questioned about their practices, 
they often point their finger back at the manufacturer.
    And so, we are left with no accountability. For the 
millions of people who are suffering in the system, these back-
and-forth arguments are frustrating and unacceptable. Everyone 
seems to be coming out ahead here--except the patient.
    No one should suffer because the high price of insulin puts 
it out of reach.
    I hope that we will learn today about why the costs of 
insulin are skyrocketing, and the role manufacturers and PBMs 
have played.
    Thank you, I yield back.
    Ms. DeGette. I thank the gentleman.The Chair asks unanimous 
consent that the Members' written opening statements be made 
part of the record. Without objection, so ordered.
    I would now like to introduce our first panel of witnesses 
for today's hearing. Mr. Mike Mason, who is the Senior Vice 
President, Lilly Connected Care and Insulins Global Business 
Unit, welcome; Mr. Doug Langa, Executive Vice President, North 
America Operations, and President of Novo Nordisk, Inc., 
welcome; Ms. Kathleen Tregoning, who is Executive Vice 
President for External Affairs, Sanofi; Mr. Thomas Moriarty, 
Executive Vice President, Chief Policy and External Affairs 
Officer and General Counsel, CVS Health; Ms. Amy Bricker, 
Senior Vice President, Supply Chain of Express Scripts; and Dr. 
Sumit Dutta, Senior Vice President and Chief Medical Officer, 
OptumRx. Welcome to all of you.
    I know you are all aware that the subcommittee is holding 
an investigative hearing and when doing so has the practice of 
taking testimony under oath. Do any of you have objections to 
testifying under oath today?
    Let the record reflect that the witnesses have responded 
no.
    The Chair then advises you that under the rules of the 
House and the rules of the committee, you are entitled to be 
accompanied by counsel. Do any of you desire to be accompanied 
by counsel during your testimony today?
    Let the record reflect that the witnesses have responded 
no.
    If you would, please rise and raise your right hand so you 
may be sworn in.
    [Witnesses sworn.]
    Ms. DeGette. You may be seated. Let the record reflect that 
the witnesses have responded affirmatively. You are now under 
oath and subject to the penalties set forth in Title 18 Section 
1001 of the United States Code.
    And now the Chair will recognize our witnesses for a 5-
minute summary of their written statements. In front of each of 
you is a microphone and a series of lights. The light will turn 
yellow when you have a minute left, and red to indicate your 
time has come to an end. I would appreciate it if you would try 
to keep your opening statements within the time frame because 
we want to make sure that all of the members have the 
opportunity to ask their questions today.
    We will start with you, Mr. Mason. You are recognized for 5 
minutes for purposes of an opening statement. Thank you.

 STATEMENTS OF MICHAEL B. MASON, SENIOR VICE PRESIDENT, LILLY 
CONNECTED CARE AND INSULINS GLOBAL BUSINESS UNIT, ELI LILLY AND 
  COMPANY; DOUGLAS J. LANGA, EXECUTIVE VICE PRESIDENT, NORTH 
 AMERICA OPERATIONS, AND PRESIDENT OF NOVO NORDISK INC., NOVO 
 NORDISK; KATHLEEN W. TREGONING, EXECUTIVE VICE PRESIDENT FOR 
 EXTERNAL AFFAIRS, SANOFI; THOMAS M. MORIARTY, EXECUTIVE VICE 
   PRESIDENT, CHIEF POLICY AND EXTERNAL AFFAIRS OFFICER AND 
     GENERAL COUNSEL, CVS HEALTH; AMY BRICKER, SENIOR VICE 
  PRESIDENT, SUPPLY CHAIN, EXPRESS SCRIPTS; AND, SUMIT DUTTA, 
 M.D., SENIOR VICE PRESIDENT AND CHIEF MEDICAL OFFICER, OPTUMRx

                 STATEMENT OF MICHAEL B. MASON

    Mr. Mason. Thank you. Chairwoman DeGette, Ranking Member 
Guthrie, Chairman Pallone, Ranking Member Walden, and other 
distinguished members, my name is Mike Mason. I am the Senior 
Vice President for Connected Care and Insulins at Eli Lilly and 
Company. Thank you for the opportunity to participate in 
today's hearing. Thanks as well to your staff who met with us. 
I'm pleased to be here today to continue that conversation.
    Eli Lilly was founded in 1876, and today employs over 
16,000 people in the United States. We are headquartered in 
Indianapolis. Lilly is proud to have introduced the first 
commercially available insulin product in 1923. For nearly a 
century, we have committed to helping people with diabetes live 
better and longer lives. We've invested billions in the 
discovery of new treatments including biotech insulins Humulin, 
Humalog, and Basaglar. In 2018, we announced our commitment to 
a research and development partnership that could eliminate the 
need for insulin. Lilly is also actively developing connected 
insulin devices that we hope will help people improve outcomes 
and adherence.
    Now, like many people who work at Lilly, I have a personal 
connection to the issues we discuss today. Four of my immediate 
family members live with diabetes. I've seen them cope with the 
daily burdens of the disease including injections before each 
meal. I've seen the devastating complications of diabetes in 
their lives and I know firsthand that they benefit from new, 
innovative treatments.
    Often our phone calls and visits turn to their diabetes. 
Over the years, we focused on these conversations on how they 
were managing their diabetes, but within the last two or three 
years, the conversations have changed. We now spend more and 
more time talking about how much they pay out-of-pocket for 
insulin. As a leader at Lilly, it's difficult for me to hear 
anyone in the diabetes community worry about the cost of 
insulin. Too many people today don't have affordable access to 
chronic medications.
    My colleagues and I have reflected on how we got here and 
what we can do to solve this problem in the short-term and 
long-term. For starters, we have not increased the list price 
for insulin since 2017, but we recognize that the issue is more 
complex than list price and it's important to focus on what 
people actually pay out-of-pocket for insulin. Most people who 
need insulins have either private or government insurance that 
requires them to pay a low, affordable copay. But some people 
don't benefit from these low copays because their out-of-pocket 
costs are based on so-called retail or list prices, not 
negotiated prices or fixed copays.
    The people most exposed in our current system are those in 
the deductible phase of high-deductible health plans, those in 
the Medicare Part D coverage gap phase, and individuals without 
insurance. We know long-term solutions are necessary, but we 
are not waiting to address the gaps in the short-term. The 
Lilly Diabetes Solution Center connects individuals to a suite 
of affordability solutions including immediate access to 
savings offers for the uninsured and privately insured, with no 
paperwork or applications.
    We provide automatic discounts at the pharmacy counter that 
cap the cost of prescription for Lilly insulin at $95 for those 
in the deductible phase of high-deductible plans. We recently 
announced the upcoming launch of a half-price version of 
Humalog called insulin lispro. With these and other meaningful 
solutions, we've tried to build a safety net preventing anyone 
from having to pay retail price for Lilly insulins.
    Our solutions are working to reduce out-of-pocket costs. 
Today, 95 percent of monthly Humalog prescriptions are less 
than $95 at the pharmacy, 90 percent are less than $50 a month, 
and 43 percent are zero. As insulin lispro launches and is 
added to formularies, even more people will pay less. Now while 
these actions ease the burdens for most people in these 
coverage gap areas, they are still stop-gap measures. Long-
term, systematic solutions are still needed.
    A good place to start is to consider the policy ideas 
suggested by CVS in their written testimony to foster the 
widespread adoption of zero-dollar copays on preventive 
medications like insulin. We agree that this solution would 
save lives and money while cutting straight to the heart of the 
affordability issue. Also, we thank this committee for its 
bipartisan action last week on legislation including the 
CREATES Act and a bill eliminating pay-for-delay tactics. 
Systematic change in our healthcare system will require action 
by all relevant stakeholders. We are ready to play our role and 
we are confident that a solution is possible.
    [The prepared statement of Mr. Mason follows:]
    
    
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    Ms. DeGette. Thank you.
    Mr. Langa, you are recognized for 5 minutes.

                 STATEMENT OF DOUGLAS J. LANGA

    Mr. Langa. Thank you, Chair DeGette, Ranking Member 
Guthrie, and members of the subcommittee. My name is Doug 
Langa. I am the Executive Vice President, North America, and I 
am the President of Novo Nordisk Incorporated.
    For over 90 years, Novo Nordisk has been dedicated to 
improving the lives of people with diabetes. We care deeply 
about the people who need our medicines and we're troubled 
knowing that for some our products are unaffordable. For a 
company committed to helping people with diabetes, patients 
rationing insulin is just simply unacceptable. Even one patient 
rationing insulin is one too many. We need to do more. We all 
need to do more. This is why I appreciate the opportunity to 
take part in a dialogue here today.
    On the issue of affordability, we all hear a lot about list 
price, and I will tell you that at Novo Nordisk we are 
accountable for the list prices of our medicines. We also know 
that list price matters to many, particularly those in a high-
deductible health plan and those that are uninsured. Why can't 
we just lower the list price and be done? In the current 
system, lowering list price won't bring meaningful relief to 
all patients, and it may jeopardize access to the majority of 
patients who have insurance and are able to get our medicines 
through affordable copays. That's because list price is only 
part of the story. Once we set the list price, the current 
system demands that we negotiate with PBMs and insurance plans 
to secure a place on their formularies. Formulary access is 
critical because it allows many patients to get our medicines 
through copays at reasonable costs. The demand for rebates has 
increased each and every year. In 2018, rebates, discounts, and 
other fees accounted for 68 cents of every dollar of Novo 
Nordisk gross sales in the U.S. As a result, net prices of our 
insulin products have declined year over year since 2015. 
Despite the investment that we make in rebates, some patients 
including those with insurance end up paying list price or 
close to it at the pharmacy counter. As a manufacturer, Novo 
Nordisk has no control over what insured patients pay at the 
pharmacy counter. This is dictated by benefit design.
    In the last few years, we've seen more patients with 
benefit designs that require them to pay high out-of-pocket 
costs, so despite these ever-increasing rebates that we pay to 
get on formularies, patients don't get the full benefit of 
those rebates at the pharmacy counter. This needs to change. 
It's time for people with diabetes to benefit directly from the 
rebates that we pay. I take the mission of this company to help 
people with diabetes very seriously and personally. I lost my 
own father-in-law to this disease, so I do know firsthand what 
it does and how it affects patients and their families.
    When the healthcare market began to shift toward high-
deductible health plans and we saw that more people were 
struggling to afford their medications, we took action. Back in 
2016, we pledged to limit list price increases to single-digit 
percentages annually. We were one of the first companies to 
make that commitment and we have honored it ever since. Our 
pricing pledge complemented other programs that we've had in 
place for years with the goal of reducing patients' out-of-
pocket costs.
    Through our nearly two decades old partnership with 
Walmart, Novo Nordisk's high-quality human insulin is available 
at Walmart pharmacies for less than $25 a vial. In 2017, we 
partnered with CVS Health and Express Scripts to expand the $25 
human insulin offerings to tens of thousands of pharmacies 
nationwide. Our human insulin is an FDA-approved, safe and 
effective treatment for both type 1 and type 2 diabetes and 
it's used by about 775,000 patients today.
    Since 2003, we have also provided free insulin to eligible 
individuals through our Patient Assistance Program. Nearly 
50,000 Americans received free insulin through the effort in 
2018 alone. Today, a family of four making up to $103,000 a 
year could qualify for a Patient Assistance Program. We also 
offer copay assistance on a wide variety of our insulin 
medicines which last year helped hundreds of thousands of 
patients lower what they pay at the pharmacy counter.
    Although these valuable programs help many people today, we 
can't stop there. Patients are telling us that we need to do 
more, and we hear them. The challenge is that the current 
system is broken. Bringing relief to patients is going to 
require bigger, more comprehensive solutions built on 
cooperation between all stakeholders in the insulin supply 
chain. We want to be a part of those solutions, and we look 
forward to working with all stakeholders to ensure that this 
lifesaving medicine remains available to everyone who needs it.
    Thank you and I do look forward to answering the questions 
today.
    [The prepared statement of Mr. Langa follows:]
    
    
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    Ms. DeGette. Thank you.
    Ms. Tregoning, now you are recognized for 5 minutes.

               STATEMENT OF KATHLEEN W. TREGONING

    Ms. Tregoning. Chair DeGette, Ranking Member Guthrie, and 
members of the subcommittee, thank you for the opportunity to 
appear before you today to discuss issues related to pricing, 
affordability, and patient access to insulins in the United 
States. I am Kathleen Tregoning, Executive Vice President 
External Affairs at Sanofi. My goal today is to have an open, 
transparent discussion about how the system works, Sanofi's 
role in it, and how it can be improved.
    Patients are rightfully angry about rising out-of-pocket 
costs for many medicines and we all have a responsibility to 
address a system that is clearly failing too many people. As a 
mom, I was heartbroken at hearing the testimony before this 
subcommittee of other parents who have not only endured the 
terrible challenge of facing illness, but have also struggled 
to afford the medications that they or their children 
desperately need.
    My own family is the beneficiary of a breakthrough in 
medicine. My husband, John, has FH, a genetic disorder that 
makes the body unable to remove LDL or bad cholesterol from the 
blood. He inherited this condition from his father who passed 
away from a heart attack at 40 years of age when John was just 
12 years old. Despite taking statins, watching his diet, and 
exercising regularly, John, himself, had a double bypass at the 
age of 36 and still couldn't get his cholesterol under control. 
Then came a class of drugs called PCSK9 inhibitors, an 
innovative treatment that helps people like my husband lower 
their bad cholesterol.
    I cannot overstate what this breakthrough means for him, 
our family, and our future, including for our 7-year-old son, 
Jack, who has inherited the same condition as his father and 
grandfather. I fully appreciate how important it is for science 
to continue to solve the medical challenges that impact so many 
families, and I recognize that those breakthroughs are 
meaningless if patients are not able to access or afford them.
    Over the last 20 years, Sanofi has been a leader in the 
advancement of new treatments to help people manage their 
diabetes. At the same time, we recognize the need to address 
the very real challenges of affordability. Two years ago, 
Sanofi announced our progressive and industry-leading pricing 
principles. We made a pledge to keep list price increases at or 
below the U.S. National Health Expenditure Projected Growth 
Rate and we stand by this commitment. In 2018, our average 
aggregate list price increase in the United States was 4.6 
percent, while the average aggregate net price, that is the 
actual price paid to Sanofi, declined by 8 percent, the 3rd 
consecutive year in which the amount we receive across all of 
our medicines went down.
    Insulin is a clear example of the growing gap between list 
and net prices. Take Lantus, for example, our most prescribed 
insulin. The net price has fallen by over 30 percent since 
2012, and today it is lower than it was in 2006. Yet, since 
2012, average out-of-pocket costs for Lantus have risen 
approximately 60 percent for patients with commercial insurance 
and Medicare.
    Every actor in the system has a role to play and Sanofi 
takes our responsibility very seriously. In addition to our 
pricing policy, we have developed assistance programs to help 
patients afford their Sanofi insulin, including copay 
assistance for commercially insured patients, including those 
in high-deductible health plans, and free insulin for uninsured 
low-income patients. Sanofi's commitment to patient 
affordability means that today approximately 75 percent of all 
patients taking Sanofi insulin pay less than $50 a month.
    But we recognized that more needed to be done. Last year, 
Sanofi launched a unique program that allowed individuals 
exposed to high retail prices to access Sanofi insulins for $99 
per vial, the lowest available cash price in the United States. 
Based on feedback from patients, providers, and the advocacy 
community, today we announced that we are expanding this 
program. Beginning in June, uninsured patients regardless of 
income level will be able to access any combination of the 
Sanofi insulin they need for $99 per month at the pharmacy 
counter.
    This transformative and first-of-its-kind program is the 
latest in a series of progressive and important steps Sanofi 
has taken to help patients afford the insulin they need. This 
action does not eliminate the need for broader system reform. I 
agree with the witnesses from last week's subcommittee hearing 
that holistic reforms to the system are not only needed but 
overdue. Sanofi also supports a number of recommendations 
outlined in my written testimony including many of the policies 
included in Chair DeGette's Congressional Diabetes Caucus 
report.
    Thank you for the invitation and I look forward to 
answering your questions.
    [The prepared statement of Ms. Tregoning follows:]
    
    
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    Ms. DeGette. Thank you so much.
    The Chair now recognizes Mr. Moriarty for 5 minutes, thank 
you.

                STATEMENT OF THOMAS M. MORIARTY

    Mr. Moriarty. Thank you, Chairwoman DeGette, Ranking Member 
Guthrie, and members of the subcommittee. My name is Thomas 
Moriarty and I serve as the Chief Policy, and External Affairs 
Officer, and General Counsel for CVS Health. Thank you for the 
opportunity to discuss ways to make healthcare more affordable, 
particularly for the millions of Americans with diabetes and 
those who are pre-diabetic.
    A real barrier in our country to achieving good health is 
cost, including the price of insulin products which are too 
expensive for too many Americans. Over the last several years, 
list prices for insulin have increased nearly 50 percent. Over 
the last 10 years, list price of one product, Lantus, rose by 
184 percent. The primary challenge we face is that unlike most 
other drug classes there have been no generic alternatives 
available even though insulin has been on the market for more 
than 30 years.
    Despite this, CVS Health has taken a number of steps to 
address the impact of insulin price increases. We negotiate the 
best possible discounts off the manufacturers' price on behalf 
of the employers, unions, Government programs, and 
beneficiaries that we serve. Our latest 2018 data indicates 
that we have been able to reduce the total cost of diabetes 
drugs including insulin by 1.7 percent, despite brand inflation 
in that year of 5.6 percent.
    Importantly, patient adherence has also increased. 
Specifically, we have replaced two very high cost insulins, 
Lantus and Toujeo, with an effective lower-cost, follow-on 
biologic called Basaglar. By making Basaglar preferred, member 
out-of-pocket costs declined by over 9 percent. Among patients 
who switched to Basaglar, their A1C or blood sugar levels were 
improved by 0.43. To put this in perspective, every one-point 
improvement in A1C among patients with uncontrolled diabetes is 
correlated with approximately $1,400 savings per year in 
medical cost for each patient. This is a real-life example of 
how competition works.
    Despite these efforts, we know this is not enough. Let me 
share a story about a company and their experience with 
diabetes. This company saw the human toll on their colleagues 
and continued to see escalating costs. In response, the company 
began offering employees and their families zero-dollar copays 
for insulin, providing coverage for diabetes medications even 
before the deductibles were met. That means there are no out-
of-pocket costs, so employees are more likely to take their 
medications, improve their health, and achieve lower costs. 
That company is CVS Health, and when something works for us, we 
offer these solutions to our clients.
    We also offer a number of tools for patients to help reduce 
their out-of-pocket costs and provide transparency at the 
doctor's office, at the pharmacy counter, and directly to the 
patient. For Caremark members, when they are in the doctor's 
office getting a prescription, we provide their doctors with 
real-time information about what is covered under their 
insurance and if there are effective, lower cost, therapeutic 
alternatives available. We also provide this information 
directly to patients online or on their phone. For CVS Pharmacy 
customers, regardless of their PBM or health plan, the Rx 
Savings Finder tool enables our pharmacists to work with 
patients to find the most affordable medications that they 
need.
    Beyond these tools, a coordinated care approach to diabetes 
is essential. We've taken the lead with a program we call 
``Transform Diabetes Car'' which furthers our focus on 
providing patient care that eases the complexity of self-
management, improves health, and reduces overall costs. Using 
connected glucometers, a high-touch engagement model, and local 
points of care, clinicians are better able to support specific 
member needs as their care requirements evolve.
    Finally, Madam Chairwoman, despite what we've accomplished 
we know that more needs to be done. Let's bring more effective, 
lower cost alternatives to market faster by ending pay-for-
delay schemes. Let's foster the widespread adoption of zero-
dollar copays on preventive medications like insulin, 
recognizing that if we treat these diseases effectively, we can 
save lives and save money, and let's pass your proposal to 
reform Medicare to provide additional support services for 
patients with diabetes to manage their own care.
    We look forward to working with you and the committee to 
help accomplish our shared goals. Thank you, and I'll answer 
any questions that you may have.
    [The prepared statement of Mr. Moriarty follows:]
    
    
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    Ms. DeGette. Thank you so much, Mr. Moriarty.
    Now, Ms. Bricker, you are recognized for 5 minutes.

                    STATEMENT OF AMY BRICKER

    Ms. Bricker. Chair DeGette, Ranking Member Guthrie, and 
members of the subcommittee, thank you for inviting me to 
testify at this hearing. My name is Amy Bricker, Senior Vice 
President of Supply Chain for Express Scripts. As a registered 
pharmacist, I began my career in the community pharmacy 
setting. As Senior Vice President of Supply Chain, I am now 
responsible for key relationships and strategic initiatives 
across the pharmaceutical supply chain working directly with 
drug manufacturers and retail pharmacies with the objective of 
keeping medicine within reach for patients including those with 
diabetes.
    Diabetes is of particular interest to me as I have 
witnessed the impacts of this disease personally. My younger 
brother, Jeff, was diagnosed with type 1 diabetes as a child. 
Diabetes is a life-changing diagnosis and can have devastating 
effects if not managed appropriately. I am passionate about 
ensuring patients have access to the medications they need. 
Today I will provide an overview of Express Scripts innovative 
approach to reduce the cost and raise the quality of care for 
people with diabetes and the more than 80 million Americans we 
serve.
    At Express Scripts we negotiate lower drug prices with drug 
companies on behalf of our clients, generating savings that are 
returned to patients in the form of lower premiums and reduced 
out-of-pocket costs. Additional savings are provided through 
our clinical support services which enable individuals to lead 
healthier, more productive lives. When it comes to prescription 
drugs, our goal is the best clinical outcome at the lowest 
possible cost.
    We offer innovative programs to help us achieve that goal 
including several programs that address the cost of insulin for 
patients. One example, our Diabetes Care Value Program closely 
manages the disease State through a holistic approach that 
combines the highest level of clinical care, advanced 
analytics, and patient engagement supported by technology. The 
program offers remote monitoring so that our specialist team 
can intervene when patient blood sugars are dangerously high or 
low. This program resulted in a 19 percent reduction in drug 
spending for diabetes.
    We launched Inside Rx, a cash discount program for patients 
that are either uninsured or faced with high co-insurance, 
partnering with drug manufacturers to provide the negotiated 
rebate at the point of sale resulting in average discounts of 
47 percent per brand drugs including an average of $150 in 
savings per insulin prescription. Our National Preferred Flex 
Formulary provides employers and health plans the flexibility 
to immediately add drugs to their formulary if a drug 
manufacturer chooses to offer a lower priced version of a drug.
    Recently, Eli Lilly announced it is reducing the list price 
of its Humalog insulin by 50 percent. We are excited about 
their decision to lower the list price on this medication and 
encourage other manufacturers to do the same. Most recently, 
Express Scripts announced the Patient Assurance Program which 
caps the out-of-pocket costs at $25 for 30-day supplies of 
insulin. We did this in collaboration with the manufacturers 
represented here today.
    Express Scripts remains committed to delivering 
personalized care to patients with diabetes and creating 
affordable access to their medication. As expressed in several 
public statements, Express Scripts welcomes lower list prices. 
However, list prices are exclusively controlled by 
manufacturers. In the absence of lower list prices, the role of 
negotiated rebates has become increasingly important as a drug 
pricing strategy.
    In today's system, rebates are used to reduce healthcare 
costs for consumers. Employers use the value of these discounts 
to keep benefit premiums affordable, and offer workplace 
wellness programs among other employee, and member-focused 
health initiatives. Half of Express Scripts clients receive 100 
percent of rebates negotiated on their behalf. In total, 95 
percent of rebates, discounts, and price reductions received by 
Express Scripts are returned to employers, plan sponsors, and 
consumers.
    Our 2018 Drug Trend Report showed a 4.3 percent decrease in 
spending for diabetes medications for plans enrolled in our 
clinical solutions. For insulin, the same plans saw a 1.5 
percent decline in unit cost. Express Scripts achieved this 
result by driving competition among manufacturers while also 
leveraging pharmacy discounts to drive savings. Looking to the 
future, we continue to support efforts by Congress and the 
administration to use market-based solutions that put downward 
pressure on prescription drug prices through competition, 
consumer choice, and open and responsible drug pricing.
    In closing, we are proud of what we have done to date, and 
we look forward to working with the committee to improve the 
affordability of insulin products. Thank you for your 
consideration of this testimony.
    [The prepared statement of Ms. Bricker follows:]
    
    
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    Ms. DeGette. Thank you.
    Dr. Dutta, you are now recognized for 5 minutes.

                    STATEMENT OF SUMIT DUTTA

    Dr. Dutta. Chair DeGette, Ranking Member Guthrie, Chairman 
Pallone, Ranking Member Walden, and members of the 
subcommittee, good morning. I am Dr. Sumit Dutta, Chief Medical 
Officer of OptumRx, a pharmacy care services company whose 
dedicated employees ensure the people we serve have affordable 
access to the drugs they need. I'm honored to be here to 
discuss steps we can all take to reduce the cost of insulin.
    The OptumRx team includes 5,000 pharmacists and pharmacy 
technicians who help patients learn how to take their 
medications, avoid harmful drug interactions, manage their 
chronic conditions. Our nurses infuse lifesaving drugs in 
patients' homes, our efforts have helped lower overprescribing 
in opioids. Our diabetes management program offers personalized 
patient-driven services to high-risk members to help them 
manage their diabetes.
    OptumRx's negotiated network discounts and clinical tools 
are reducing annual drug costs on average by $1,600 per person 
for our customers. Our efforts start with a clinical assessment 
by our pharmacy and therapeutics committee comprised of 
independent physicians and pharmacists. They evaluate our 
formularies based on scientific evidence, not cost. These 
meetings are open and transparent to our customers. Cost only 
becomes a factor after this independent committee has 
identified clinically-effective drugs in a therapeutic class.
    Because OptumRx promotes the use of true generics to drive 
costs lower through competition, about 90 percent of the 
prescription claims we administer are for generics. 
Unfortunately, in the case of insulin there are no true generic 
alternatives. Because many branded insulin products are 
therapeutically equivalent, we negotiate with brand 
manufacturers to obtain significant discounts off list prices 
on behalf of our customers.
    Already, 76 percent of the people we serve who need insulin 
pay either nothing at the pharmacy or have a fixed copay, most 
commonly $35. For insulin users on high-deductible or 
coinsurance plans, we have taken action to help them directly 
benefit from the savings we're negotiating with manufacturers. 
Last year, we dramatically increased the discounts at the 
pharmacy counter for millions of eligible consumers who are now 
seeing an average savings of $130 per eligible prescription and 
the savings are even higher on insulin.
    Last month, we announced the decision to expand this point-
of-sale discount solution to all new employer-sponsored plans 
beginning January 2020. Nevertheless, the price of insulin 
remains too high. A lack of meaningful competition allows 
manufacturers to set high list prices and continually increase 
them which is odd for a drug that is nearly 100 years old and 
which has seen no significant innovation in decades. These 
price increases have a real impact on consumers in the form of 
higher out-of-pocket costs.
    The most impactful way to reduce insulin prices is by 
opening the market to true generics and biosimilars. This is 
why we support efforts to reform the patent system and promote 
true generic competition. For years, insulin manufacturers have 
used loopholes in the patent system to stifle competition. One 
manufacturer has filed 74 patents on one brand to prevent 
competition. Others have engaged in multiyear patent disputes 
to delay the introduction of lower cost products.
    Congress can increase competition and lower prices by 
passing the CREATES Act, prohibiting pay-for-delay deals and 
evergreening of patents, accelerating biosimilar options, and 
reducing the exclusivity period for drugs. We are committed to 
doing our part to make insulin more affordable. I would be 
pleased to answer any questions you have.
    [The prepared statement of Mr. Dutta follows:]
    
    
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    Ms. DeGette. Thank you, Dr. Dutta.
    It is now time for the Members to ask questions and the 
Chair recognizes herself for 5 minutes.
    I appreciate all of your testimony. What strikes all of us 
on this panel, which we have heard from all of the actors in 
the system, is how the list price is really high, but then 
there are all these workarounds that some people can get to get 
a lower price of insulin, and let me just give you an example. 
Eli Lilly increased the price of Humalog from $35 in 2001 to 
$275 today. Novo Nordisk increased the list of NovoLog by over 
350 percent since 2001. And on January 8th of this year, the 
insulin products of Novo Nordisk went up by 5 percent. Sanofi 
increased the price of Apidra from $86 in 2009 to $270 last 
year. And so, since January 1st, the three main brands were 4.4 
to 5.2 percent gone up this year.
    And most everybody here now knows my daughter Francesca, 
who is 25, she is a type 1 diabetic. I am not going to put 
anybody on the spot, but she is on a newer kind of insulin and 
she has insurance. She is still on my insurance for eight more 
months--who is counting--and she renewed her prescription at 
the beginning of the year. And for this insulin it says on the 
receipt the retail price, $1,739.79, ``Your insurance saved you 
1,399.79.'' But for her type of insulin she is on, the list 
price is $347.80 per bottle. Now she didn't pay that because 
she is on insurance, but she still paid quite a bit because I 
have a pretty high deductible.
    So here is the thing everybody is saying, ``Well, sure the 
list price is high, but there are all these workarounds.'' But 
not everybody gets the workarounds, and the question is why is 
the list price so high? So, I am going to ask each one of you, 
and I have really limited time.
    Mr. Mason, I am wondering if you can tell me in 30 seconds, 
how does Eli Lilly justify these huge increases in list prices 
in the past 10 or so years?
    Mr. Mason. Thank you for the question. I hope your daughter 
is doing well.
    Ms. DeGette. Yes, forget about that. Just, please.
    Mr. Mason. Seventy-five percent of our list price is paid 
for rebates and discounts to secure access, so people have 
affordable access----
    Ms. DeGette. That is what is making the price go up and up?
    Mr. Mason. Two hundred and ten dollars of a vial of Humalog 
is paid for discounts and rebates.
    Ms. DeGette. OK, Mr. Langa, same question.
    Mr. Langa. So as you heard last week from Dr. Cefalu from 
the ADA, there is this perverse incentive and misaligned 
incentives and this encouragement to keep list prices high, and 
we've been participating in that system because the higher the 
list price, the higher the rebate.
    Ms. DeGette. So, you also think it is because the rebates 
that the prices have gone up so much in the last 10 years?
    Mr. Langa. There's a significant demand for rebates. We 
spend almost $18 billion.
    Ms. DeGette. OK, I am sorry.
    Ms. Tregoning. Yes, as part of how we set list prices, we 
have to look at the dynamics of the supply chain including the 
rebates. We have at Sanofi limited ourselves to list price 
increases no greater than national health expenditures across 
every one of our products.
    Ms. DeGette. OK.
    OK, now, Mr. Moriarty, I bet you have a different 
perspective on why the list price of insulin is so high.
    Mr. Moriarty. Chairwoman, rebates are discounts. And as 
we've disclosed, more than 98 percent of those discounts go 
back to our clients.
    Ms. DeGette. I understand, but why do you think the list 
prices are so high?
    Mr. Moriarty. I can't answer that. That is the 
pharmaceutical manufacturers' purview.
    Ms. DeGette. But you don't think it is because of 
discounts?
    Mr. Moriarty. I do not, no.
    Ms. DeGette. Ms. Bricker?
    Ms. Bricker. I concur. I have no idea why list prices are 
high and it's not a result of rebate.
    Ms. DeGette. Dr. Dutta?
    Dr. Dutta. We see list prices rising double digits in non-
rebated drugs, in generics where monopolies lost, or where 
manufacturers buy up and create monopoly, so we can't see a 
correlation just when rebates raise list prices.
    Ms. DeGette. OK, so of course my time is almost up, but I 
think this is a good example of the problem that the Members of 
Congress are dealing with in trying to figure out how to solve 
this problem. Because it seems to me what is happening is that 
every component of the drug system is contributing to an upward 
pressure on the list price.
    I know the members are going to have a lot of questions 
around that and we will do some follow-up at the end, so I 
would like to recognize the ranking member for his input, for 5 
minutes.
    Mr. Guthrie. Thank you very much. Thanks for being here. I 
am going to use a quick example just because I am trying to 
make it simple. I have been wrestling with this for about a 
month in trying to figure out what is happening.
    If Chair DeGette was making this phone and I want to buy it 
and she said she is willing to take $100 for it, but she says, 
``I will sell it to you for 300,'' and give me 200 back, and 
that doesn't make sense. Or Chair DeGette is willing to take 
$100 and I say to her, ``Hey, I am willing to pay 100, but 
charge me 300 and I will give you 200 back.'' The whole idea is 
that Brittany is the purchaser at the end and I am passing, I 
am giving that to her for $100 because she is the plan, she is 
saving the money and passing it on to her consumers, and what 
we are trying to figure out is where that delta is going. It is 
just hard to figure out and I have been spending a lot of time 
on it.
    On February 6th, so the three manufacturers, I want to try 
to, because I have a few questions so try to go fast, you said 
that your list price has gone up, but your net price has gone 
down. What would happen if you just said, ``Hey, I want to make 
my list price my net price, and put it out on the 
marketplace?''
    So I'll let you three.
    Mr. Mason. First of all, we are dropping our list price of 
Humalog by 50 percent with our launch of lispro insulin. For us 
there are many people who have access. The majority of people 
have access for insulin at affordable cost through their plans. 
That's not tied to list price, so we don't want to disrupt 
those by lowering list price. We think the best way is to 
provide in the short-term is to keep our list price at the way 
it is; so we don't disrupt those individuals, we don't harm the 
access that they have.
    Mr. Guthrie. But if you are willing to take, I think you 
said you had, I don't know, whatever the net price is, I know 
net prices are different with different plans. There is not one 
net price, I get it. But if you are willing to take a net price 
for your product and three of you here, why wouldn't that be 
something out there for everyone to pay? I mean that is what 
you are willing to charge, right?
    Mr. Mason. It's just more difficult to do that to disrupt 
that for a product that's on the marketplace today, because 
people have affordable access.
    Mr. Guthrie. But you have had your net price and according 
to your testimony go up 207 percent while your list price 
dropped by 3 percent, according to the letter on February 6th 
on Humalog.
    I think you all are similar too. I don't want to just do 
Lilly, all of you guys as well. I mean that is kind of, so we 
see the net price going--I understand what you are saying, but 
we see the net price rising. We want to know why it is doing 
it? Maybe there is a market reason for that and it is 
benefiting consumers, but we want to know.
    Mr. Langa. In the current system today, the most important 
thing for us is for the most number of patients to get our 
brands at the most affordable prices, and in the system today 
that is the current formulary positions. Just the three PBMs 
here today represent over 220 million covered lives.
    Mr. Guthrie. OK, you said they were perverse. OK, I am 
running out of time.
    Mr. Langa. So that is 80 percent of the lives, so for us to 
lose one of those positions that would be a dramatic impact to 
patients in terms of the medicine that they are on, physicians 
in terms of their choice.
    Mr. Guthrie. Your argument is----
    Mr. Langa. And there would be----
    Mr. Guthrie [continuing]. You would lose your position on 
the formulary if you lowered your price?
    Mr. Langa. In the current system if we eliminated all the 
rebates, yes.
    Mr. Guthrie. You are shaking your head, the same way?
    Mr. Langa. We believe that we would be in jeopardy of 
losing those positions.
    Mr. Guthrie. You said there were perverse incentives. What 
are the perverse incentives?
    Mr. Langa. Well, we're spending almost $18 billion a year 
in rebates, discount, and fees, and we have people with 
insurance with diabetes that don't get the benefit of that.
    Mr. Guthrie. What are the perverse incentives for that 18 
billion in rebates? You said they are perverse----
    Mr. Langa. They're going into the system and they're 
misaligned, right, so that's, we believe that they should go 
back to the diabetic patient.
    Ms. Tregoning. The issue here, Congressman, is not one of 
negotiation. The PBMs are very effective negotiators. It's what 
happens with the results of that negotiation. Those rebates are 
not necessarily going all the way through to patients. They're 
being used for other parts of the system, and we don't have 
visibility to how those rebates get used. Those rebates are 
part of how we secure formulary placement and cost sharing for 
the patients that are covered by those plans.
    Mr. Guthrie. So you say, ``I am willing to take X for a 
product, but for me to get on their formulary, I know I am 
going to have to raise my list price because they then want 
rebates,'' is that what you are arguing?
    Ms. Tregoning. The rebates are how the system has evolved. 
The rebates are part of the negotiation to secure formulary 
placement and associated----
    Mr. Guthrie. I went too long on that side because I am not 
giving you--you already talked to that, I guess. I had other 
questions, but I would rather hear your responses to that.
    Ms. Bricker. So as mentioned previously by my colleague to 
my left, of course we're looking at the clinical attributes of 
a product and I know you want to get to the economics. The way 
we make formulary decisions is based on net price. If every one 
of the manufacturers to my right wanted to reduce their list 
price, there would be no implication to the rebate status so 
long as the net price remained the same.
    Mr. Guthrie. So on my example, if she is willing to sell 
for me a hundred and I sell to Brittany for a hundred, and you 
are saying rebates keep the price down, but in the end because 
you are selling to her at the net price, so why wouldn't the 
net price be--what we are trying to figure out is it seems like 
there is a price that is marked through the system that seems 
to be based on something, but there seems to be an inflation 
and another higher price that just seems to be caught up in the 
system.
    But what really affects people as we have talked about, 
when they are going to the point of sale when they haven't hit 
their deductible. I know you have these plans in place and 
those are great, but we need to figure out the economics behind 
it; so if we need to do something here to help people out, we 
need to understand that.
    I wish we had more than 5 minutes. I yield back.
    Ms. DeGette. The Chair recognizes Mr. Kennedy for 5 
minutes.
    Mr. Kennedy. Thank you. I want to thank the witnesses here 
and I want to thank the Chair and ranking member for holding 
this hearing.
    I am going to follow up on some of the questions that have 
already been asked. I want to submit for the record though a 
Boston Globe piece from last November. I have done this before 
in other hearings about individuals, two mothers that brought 
ashes of their children in front of Sanofi in Boston, in 
Cambridge, back in November trying to protest these prices.
    You all have, you know why we are here, and you know what 
the challenges are. I can tell you even from being here for a 
couple minutes how frustrating it is to be on this side of the 
dais, and watch everyone do this. So I also, I hope, and I 
expect that you will also understand that if that is the result 
of this hearing that we are not, you are hearing bipartisan 
frustration on this. You are not going to--the status quo is 
not going to continue, it can't.
    We heard testimony last week from patients that were 
literally rationing, putting their lives on hold, or taking 
serious risks for themselves and their children, to be able to 
get access to medicine that was patented and sold for a dollar.
    And, sir, Mr. Mason, you began by saying about the 75 
percent of that increase over the course of the past several 
years increase in list price goes to PBMs. The data that I have 
indicates that over the past--since 2002 to 2013, Endocrine 
today estimated the average price went from $231 in 2002 to 
$736 in 2013, inflation adjusted. Seventy-five percent of that 
is roughly $375. That means 127--50 percent of that baseline 
price is not PBMs.
    Where is the other 50 percent? What justifies the other 
$127 increase?
    Mr. Mason. You know, our net prices have gone down since 
2019, so the--or since 2009. We haven't taken a price increase 
until since 2017.
    Mr. Kennedy. Sir, have you ever lowered a price off of your 
formulary?
    Mr. Mason. We are launching a lower priced Humalog that's 
50 percent off.
    Mr. Kennedy. It took 15 years and global outcry on this to 
do it? What factors go into--have you ever lowered the price 
off of a formulary?
    Mr. Mason. We have lowered our net price over the last 10 
years.
    Mr. Kennedy. What factor goes into lowering that price? 
What evaluation do you take to lower that price?
    Mr. Mason. What evaluation, you know, a decade ago we were 
on formularies, all formularies, now we're on formularies 
about, you know, half, about half of formularies, patients in 
America have our insulins because we're moving to strictly 
formularies. We have to provide rebates in order to provide and 
compete for that so people can use our insulin.
    Mr. Kennedy. Mr. Langa, have you ever lowered a list price?
    Mr. Langa. We have not.
    Mr. Kennedy. Why not?
    Mr. Langa. For two reasons, as I said the biggest vehicle 
today for the most majority of patients in this country----
    [Simultaneous speaking.]
    Mr. Langa. No, it's formulary position. So that's the best 
way for us today to reach the most amount of patients in an 
affordable way and anything that risks that is something that 
we have to strongly consider. Everything's on the table right 
now for Novo Nordisk. We want to be part of the solution.
    Mr. Kennedy. If it takes us hauling you in after people are 
telling us that they are rationing the lives of their children, 
how does this work? I understand that part of this comes back 
on us. You guys are responding to incentives that Congress sets 
and a lack of regulation, a lack of oversight to allow this to 
happen. But from my position at the moment, trying to figure 
out what levers to push and pull, we are asking what goes into 
the factors to set that list price, we don't get an answer. To 
lower risk price, it either hasn't happened or we don't know. 
You place the blame on the major of the hike of it to going on 
the PBMs and the PBMs are putting it back at you.
    If you were in my position, what do we do to try to make 
sure that patients in this country get access to lifesaving 
medication, that was initially discovered for a buck and sold 
to a university, to ensure that every person could get access 
to it? What do you suggest?
    Mr. Langa. I suggest that we all come together to come up 
with solutions, get together with Congress to make sure that 
rationing never happens again. As I mentioned in my opening 
statement, one patient is too many. And as an organization 
that's for 90 years been committed to patients with diabetes, 
it's tragic and it should never happen.
    Mr. Kennedy. Ms. Tregoning?
    Ms. Tregoning. Congressman, no one should be rationing 
insulin. No one----
    Mr. Kennedy. And they do every day.
    Ms. Tregoning. We need to make those patients more aware of 
the programs that are available.
    Mr. Kennedy. What do you do--the programs, ma'am, there 
were people here last week that said those programs take weeks 
to get into that there are not transparency on it. They can't 
wait six weeks to get an insulin shot.
    Ms. Tregoning. Congressman, our copay assistance programs 
can be accessed in a matter of minutes online, and so, people 
with high-deductible health plans----
    Mr. Kennedy. Do you have any patients that don't have 
access to internet?
    Ms. Tregoning. We also have phone numbers where patients 
can call.
    Mr. Kennedy. How long does it take for them to be able to 
access those programs? What percentage of folks do you deny?
    Ms. Tregoning. For copay assistance and for--we have, it's 
literally a matter of moments for the VALyou Savings Program 
that we accessed, that we announced today, the expansion----
    Mr. Kennedy. That you announced today when you are in front 
of Congress?
    Ms. Tregoning. It's an expansion of a program that we 
started last year, $99 for the insulin that they need in any 
combination at the pharmacy counter; people can get access to 
that. It's for uninsured patients. For those with high-
deductible health plans, they can access copay assistance 
that's no more than a $10 copay.
    Mr. Kennedy. I am way over time.
    But for the folks that are uninsured that are paying your 
full list price----
    Ms. Tregoning. For the folks that are uninsured paying full 
list price----
    Mr. Kennedy. I yield back.
    Ms. Tregoning [continuing]. They now have access as of 
June, $99 at the pharmacy counter for the insulin that they 
need per month.
    Ms. DeGette. The Chair recognizes the ranking member of the 
full committee, Mr. Walden, for 5 minutes.
    Mr. Walden. Thanks again, Madam Chair, for having this 
hearing. Thanks again to our witnesses for being here.
    Ms. Tregoning, in 2018, Sanofi launched Admelog. Now I 
understand that is a follow-on biologic to Eli Lilly's Humalog. 
Now according to press articles, Sanofi launched Admelog at a 
list price that is about 15 percent less than the list price 
for Humalog. Is that pretty close?
    Ms. Tregoning. Yes. It's the lowest rapid-acting list 
priced insulin.
    Mr. Walden. OK. Typically, when a generic medicine enters 
the market, we expect for the price of the generic to be less 
than the branded; and many patients to switch from the brand 
medicine to the generic medicine. You have told us, however, 
that Admelog is not on the formulary for any commercial plans. 
I believe that is correct?
    Ms. Tregoning. No. Yes, correct. It's only available 
through Managed Medicaid.
    Mr. Walden. Given that Admelog was launched at a lower list 
price than Humalog, what barriers are preventing patients from 
this alternative and are there issues gaining formulary access 
for Admelog?
    Ms. Tregoning. Congressman, we were unable to secure 
formulary access through rebating with Admelog. As to exactly 
why those decisions were made, I'd have to defer to my 
colleagues on the other side of the panel.
    Mr. Walden. Has Sanofi faced these barriers for launching 
any other products?
    Ms. Tregoning. Yes, Sanofi has brought a number of products 
to patients at lower prices including Kevzara, which is a lower 
list price of a rheumatoid arthritis medicine, and we similarly 
face challenges.
    Mr. Walden. Given Sanofi's experience with Admelog, do you 
think more follow-on biologics and biosimilars of insulin will 
help reduce the list price of insulin, or does the biologic 
market function differently than introduction of a generic of a 
small molecule drug?
    Ms. Tregoning. There is already competition in the insulin 
market as I believe one of the colleagues referenced. Eli Lilly 
introduced a follow-on biologic version of Lantus several years 
ago and so there is competition. CVS in its testimony spoke to 
the fact that they were able to leverage greater rebates and 
negotiate through that.
    Mr. Walden. Now, I want to switch to Mr. Mason and thanks 
again for being here. We have heard that sometimes a branded 
biologic manufacturer may tell pharmacy benefit managers, PBMs, 
and health insurance plans that they will no longer provide 
rebates for their branded product, if the PBM or health 
insurance plan puts a follow-on biologic or biosimilar on the 
formulary. Has Eli Lilly told any PBMs or health insurance 
plans that it will no longer provide rebates for Humalog if the 
PBM or health insurance plan puts Admelog on its formulary?
    Mr. Mason. No, we haven't.
    Mr. Walden. All right.
    Ms. Tregoning, similarly did Sanofi tell any PBMs or health 
insurance plans that it would stop providing rebates for Lantus 
if the PBM or health insurance plan put Basaglar on their 
formulary?
    Ms. Tregoning. No, nothing.
    Mr. Walden. Mr. Moriarty, has a manufacturer ever said they 
would stop providing you rebates for a product if you put a 
competing product on your formulary?
    Mr. Moriarty. Not that I'm aware of, sir.
    Mr. Walden. OK, so that has never happened.
    Mr. Moriarty, Ms. Bricker, and Mr. Dutta, why isn't Admelog 
included on your formulary?
    Ms. Bricker. The challenge that we have with Admelog 
specifically is one of net cost. And so through the mechanisms 
that we use today, which are rebates or discounts, it was more 
expensive than competing product. Manufacturers do give higher 
discounts for exclusive position, so I think that was your 
question to my counterpart here on the right.
    Mr. Walden. Yes, if each of you could answer that.
    Ms. Bricker. Yes, so to the extent that we have recognized 
one product as exclusive, other manufacturers will--that 
exclusive product will receive less discount if additional 
products are added.
    Mr. Walden. Why not include both?
    Ms. Bricker. We'll receive less discount in the event that 
we do that.
    Mr. Walden. What?
    What about the others on the panel, Mr. Dutta and Mr. 
Moriarty, can you speak to this?
    Dr. Dutta. The lowest cost product gets preferential 
position on our formulary. So, for example, generics which are 
very low cost have preferential position.
    Mr. Walden. OK.
    Mr. Moriarty?
    Mr. Moriarty. Similarly, we drive to lowest available cost, 
lowest cost product. And with the example of Basaglar we were 
able to move that follow-on biologic to preferred status and 
actually have most, if not all, patients now on that one.
    Mr. Walden. We keep hearing the manufacturers should just 
lower their list prices, but a lower list price doesn't 
necessarily guarantee that a manufacturer will have access to 
patients, or that that patient will pay a lower price at the 
pharmacy counter. Do you take the list price of a medicine into 
consideration when making formulary decisions?
    Mr. Moriarty. We do not. We focus on the lowest available 
cost, the lowest net cost.
    Mr. Walden. All right.
    Ms. Bricker?
    Ms. Bricker. The same, yes, lowest net cost.
    Mr. Walden. Mr. Dutta?
    Dr. Dutta. Lowest net cost, and for the member we consider 
their cost by using point-of-sale discounts and in order to 
lower their cost out-of-pocket.
    Ms. DeGette. I just want to follow up on the ranking 
member's questions for Mr. Moriarty and Dr. Dutta. Why then if 
you look at generics and the lowest cost, why aren't either of 
your PBMs putting Admelog on these plans?
    Mr. Moriarty. Madam Chair, we have gone with Basaglar as 
the follow-on biologic alternative and the preferred status for 
that category.
    Ms. DeGette. OK.
    Dr. Dutta?
    Dr. Dutta. It would cost the payer more money to do that.
    Ms. DeGette. Why?
    Dr. Dutta. Because the list price is not what the payer is 
paying. They're paying the net price.
    Ms. DeGette. The Chair now recognizes Dr. Ruiz.
    Mr. Ruiz. Thank you, Chairwoman.
    The rising cost of drugs is such a big problem that it has 
reached kitchen table, family conversations across America. 
Those families are struggling, worried about having to decide 
between paying for insulin or paying their bills. There has 
been a lot of rhetoric today, and finger pointing in the drug 
pricing debate; and oftentimes the conversation is based on 
theoretical arguments about what will work for manufacturers, 
or PBMs, or insurance companies, with little regard to what 
works for patients.
    As a doctor, I put my patients' needs above all else and 
our solutions should do the same and reduce out-of-pocket costs 
for patients. In my district, according to the Health 
Assessment & Research for Communities 2016 survey, one out of 
four adults diagnosed with diabetes in the Coachella Valley are 
living below the Federal poverty line; and over 10 percent of 
adults diagnosed with diabetes do not have health insurance 
that covers some or all of the cost of their prescription 
drugs. This is not just a problem for the uninsured or 
underinsured either.
    Just this week I heard from Tamara Smith and David Richard, 
two constituents who had to go on a specialized form of insulin 
that isn't covered by their insurance. That means hundreds of 
dollars more out-of-pocket every month. So reducing the list 
prices of drugs or increasing the number of generics does not 
solve the problem, if these savings are not lowering out-of-
pocket costs for people like Tamara and David. The CEO of 
Diabetes Patient Advocacy Coalition drove home this point in 
her testimony last week in stating, ``Somebody's making a 
profit and it's not the patients.''
    So, Mr. Mason from Eli Lilly, who is making a profit from 
these increases in insulin prices?
    Mr. Mason. You know, I think, first of all, we don't want 
anyone not to be able to afford their insulin.
    Mr. Ruiz. Who is making a profit with these increases in 
insulin prices that patients have to pay for?
    Mr. Mason. Our net price is the price that we receive are 
going down.
    Mr. Ruiz. Are you?
    Mr. Mason. No.
    Mr. Ruiz. Are you making a profit? Are the CEOs of your 
companies making these profits?
    Mr. Mason. Our net prices, the price that we receive has 
gone down since 2009.
    Mr. Ruiz. Well, somebody is making a profit. Somebody is 
getting richer on the backs of our patients.
    Mr. Langa from Novo Nordisk, what entity in the supply 
chain is prioritizing affordability and access of insulin for 
patients?
    Mr. Langa. Well, we'd like to think we are. I mean we 
participate in as many formularies as we can. As I've mentioned 
that is critically most important. We have Patient Assistance 
Programs as well as copay assistance programs.
    Mr. Ruiz. Who is making a profit then?
    Mr. Langa. Well, our nets are going down as well, but there 
is a small profit that----
    Mr. Ruiz. Your nets, but your overall profits for the 
company and CEOs have been going up, haven't they?
    Mr. Langa. No. Our profit has been----
    Mr. Ruiz. Take-home pay from CEOs?
    Mr. Langa. Our profits have been relatively stable.
    Mr. Ruiz. From CEO pay hasn't gone up in the past several 
years?
    Mr. Langa. His pay has increased, yes.
    Mr. Ruiz. OK.
    So last week, Dr. Cefalu from the American Diabetes 
Association noted that PBMs' primary customers are the health 
plans and insurers not the patients. He testified, ``We don't 
know whether those transactions are actually benefiting the 
patient at the point of sale.''
    Ms. Bricker from Express Scripts, does Express Scripts pass 
any savings on to beneficiaries; and how do we know what the 
difference is if there is not that transparency?
    Ms. Bricker. So yes, thank you for the question. For over 
20 years, Express Scripts has supported point-of-sale rebates. 
We do have clients and plan sponsors that are----
    Mr. Ruiz. How do we know what the percentage of that cost 
savings to patients, is if we don't have transparency of what 
the savings are? Are they going to your clients' profit or are 
they going to reducing out-of-pocket costs? How do we know?
    Ms. Bricker. So we support transparency for our plan 
sponsors, those that hire us. They absolutely have the ability 
to look at all of our rebate negotiated contracts as well as 
our retail contracts. We believe in transparency for patients.
    Mr. Ruiz. So we need to look into what you say, and what is 
actually being done with implementation and that is what the 
purpose of this is for.
    Mr. Moriarty from CVS Health, are these barriers to passing 
discounts on to patients at the point of sale and, if so, what 
are they?
    Mr. Moriarty. Sir, we have over ten million lives covered 
in a point-of-sale rebate program today. We also, as you heard 
in my written testimony and oral testimony, we really advocate 
a zero copay for insulin and other preventive medications. The 
cost savings associated with adherence is significant.
    Mr. Ruiz. OK, I got 20 seconds so let me ask this question 
directly. What are each one of you willing to give up to make 
sure that every patient who needs insulin will get insulin? Mr. 
Mason?
    Mr. Mason. We are willing to provide solutions, and we are 
providing solutions that close the gap to anyone paying out-of-
pocket----
    Mr. Ruiz. What are you willing to give up?
    Mr. Mason. We're willing to give up--we gave up $108 
million last year.
    Mr. Ruiz. Mr. Langa, what are you willing to give up?
    Mr. Langa. Last year we invested almost $18 billion in 
rebates, discounts, and fees; and we also spent 200----
    Mr. Ruiz. But yet the prices are still going up, so the 
status quo isn't working.
    Ms. Tregoning, what are you willing to give up?
    Ms. Tregoning. We are willing to contribute to solutions to 
allow patients to access, and that's why the program that we 
have allows $99 at the pharmacy for the insulin----
    Mr. Ruiz. Those solutions aren't working if we are seeing 
doubling, tripling, cost of insulin and our patients are having 
to ration and not afford their insulin.
    Ms. Tregoning [continuing]. And that costs are going down.
    Ms. DeGette. The gentleman's time has expired.
    The Chair now recognizes the gentleman from Virginia, Mr. 
Griffith, for 5 minutes.
    Mr. Griffith. Thank you, Madam Chair.
    Mr. Mason, Ms. Tregoning, and Mr. Langa, we have heard that 
there are numerous fees and discounts in the prescription drug 
supply chain that are calculated based on insulin prices. 
According to what I have read, you all have fees with your 
supply chain partners that are based on a percentage of the 
list price of insulin. Why are they structured this way?
    You are up first, Mr. Mason, let's go. Time is running.
    Mr. Mason. We don't--the PBMs kind of own the paper of the 
contracts and that's what we have to work with.
    Mr. Griffith. All right.
    Mr. Langa?
    Mr. Langa. It's the current system.
    Ms. Tregoning. Agreed, it's the current system.
    Mr. Griffith. All right. Have any of your companies tried 
to negotiate flat fees with your supply chain partners?
    Mr. Mason. Yes, we have.
    Mr. Langa. We have tried a variety of different avenues 
with contracting.
    Mr. Griffith. But you have not been successful, why?
    Mr. Mason. No, our efforts were pushed away.
    Mr. Langa. I think it's because it's the current system and 
again in this demand for rebates today.
    Mr. Griffith. Ms. Tregoning?
    Ms. Tregoning. Yes, again it's the system under which we 
operate.
    Mr. Griffith. So other than just it's the system, what 
reasons did the other participants in the supply chain provide 
to justify a fee based on the list price of the medicine rather 
than a flat fee?
    Mr. Mason. It's the current system.
    Mr. Griffith. Just the current system, everybody agree with 
that? All right, because I will move on.
    Mr. Moriarty, in the February 6th letter that we sent to 
CVS Health, we specifically asked CVS Health to list all the 
contractual terms in your existing contracts that are impacted 
by the list price of a medicine. CVS Health did not directly 
answer whether there were any fees charged by CVS that are 
calculated as a percentage of a list price.
    While reviewing the standard contract template commonly 
utilized between CVS Caremark and a health plan client for 
several lines of business that the committee received in 
response to a letter that we sent to CVS Health last August, we 
saw that there was a section in the template on disclosure of 
manufacturer fees, that are disclosed that Caremark Part D 
services may also receive administrative fees from 
pharmaceutical companies that are based on a percentage of the 
list price of the medicine. It therefore appears as though CVS 
Health may use administrative fees that are based on a 
percentage of the list price of a medicine. This is correct, 
isn't it?
    Mr. Moriarty. Congressman, over 98 percent of all the fees, 
rebates that we obtain across our services and 100 percent in 
Medicare go back to the plan sponsors.
    Mr. Griffith. That is not what your contract says. Your 
contract says you all can charge a one percent fee, an 
administrative fee based on the price of the medicine. The 
question that I have is, it doesn't cost your company any more 
to process a $4 drug than it does a $40,000 drug; isn't that 
correct?
    Mr. Moriarty. It represents the costs associated with that 
processing, sir.
    Mr. Griffith. Well, wouldn't it make more sense from a 
consumer's standpoint that you came out and be more 
transparent, but that you came out with a flat fee and worked 
with these folks over here to come up with a flat fee? Because 
I understand in Part D on Medicare you are just charging the 
one percent, but across the board according to your information 
you sent us you are charging two percent. As a part of the 
rebate you are getting two percent of that, and I don't know 
whether you are charging those folks an administrative fee or 
not, but wouldn't it make more sense just to have a flat fee 
for doing what you all do?
    Mr. Moriarty. If the flat fee represents what the current 
net pricing, the lowest pricing it is in the market, yes, we 
will do that.
    Mr. Griffith. You are willing to do a net, even if it costs 
your company some profit you are willing to do a flat fee?
    Mr. Moriarty. Here's the issue. I think what's been 
proposed before actually results in not lower costs, actually 
higher costs. If it results in lower costs, we will implement 
that.
    Mr. Griffith. I mean because one of the problems we have is 
if you are not in one of the magic companies you are paying the 
list price and you are not able to afford it, or you are paying 
the high deductible in order to get there because you haven't 
reached your deductible yet. And lots of people have opted for 
these plans, and so the consumer is having to pay that higher 
list price, they aren't getting all those rebates all the time, 
and as a result of that their net price has gone up 
substantially. That is what we're hearing from our constituents 
who are having to pay that. It just seems to me that it ought 
to be something that we all can look at, the whole system needs 
to be more transparent; and that you all ought to be paid for 
processing that prescription whether it is a $4 drug or a 
$40,000 drug, you ought to be charged a set standard fee that 
doesn't have the drug companies coming in here saying, ``We are 
raising our list price,'' so they can get more.
    By the way, how many billions of dollars, or at least 
hundreds of millions of dollars is represented by that one or 
two percent?
    Mr. Moriarty. We pass back as I said over 98 percent, and 
we had disclosed publicly what the retained number is.
    Mr. Griffith. What is the dollar number?
    Mr. Moriarty. The total number across is $300 million.
    Mr. Griffith. I yield back.
    Ms. DeGette. Thank you.
    Mr. Kennedy offered an article for the record and, without 
objection, it shall be entered.
    [The article appears at the conclusion of the hearing.]
    Ms. DeGette. The Chair now recognizes the chairman of the 
full committee, Mr. Pallone, for 5 minutes.
    Mr. Pallone. Thank you, Madam Chair. I missed a lot of the 
hearing because we had other hearings, and we were on the floor 
today with net neutrality. But I just want to say this. All I 
hear from my constituents, they are just totally disgusted, 
right. They figure particularly for insulin it has been around 
a long time, you know, they don't even believe in a market-
based system anymore.
    I mean, frankly, I believe in a market-based competitive 
system. I think that, you know, that is what the country is all 
about. But what they tell me is, just set the price. They will 
literally say to me, ``You in Congress or some Government 
agency should just set the price and that is it.'' They just 
don't believe in a competitive model anymore. So, you know, you 
keep saying the system, the system, the system doesn't work, 
well, I guess part of what I would like to know is why this 
marketplace competitive model doesn't work anymore. What has 
happened?
     So, you know, last week the committee heard from Dr. 
Lipska, who is a clinician and researcher, and she said, and I 
quote, ``Drug makers make excuses for why prices have gone up. 
They say it's the fault of PBMs, or wholesalers, or the high 
deductible insurance plans, but the bottom line is that drug 
prices are set by drug makers. The list price for insulin has 
gone up dramatically and that's the price that many patients 
pay. That is what needs to come down. It's as simple as that.'' 
Now, many of my constituents say, very simple, set the price. 
Have the Government set the price and not have the company set 
the price. But I mean that is not the competitive model 
obviously. So let me just start.
    Mr. Mason, you set the list price for your insulins, not 
the PBMs or anyone else in the supply chain. Why are we talking 
about high drug prices when it is within your power to bring 
the list prices down? Why don't you just bring the list price 
down, or do you want us to set it? Because that is what my 
constituents say. Don't have Mr. Mason set it, you set it. Let 
the government set it. Why not, if you are not going to do 
anything?
    Mr. Mason. OK, so we--well, we actually buy down everyone 
in a high-deductible plan down to $95, so we're doing that 
today. Everyone who has, on a Lilly insulin at the pharmacy we 
buy every prescription down to $95, so we are reducing the list 
price. We're paying rebates in order to get access and----
    Mr. Pallone. Are you willing to reduce it more?
    Mr. Mason. We right now reduce, you know, no matter how 
much their--you mean, they can use multiple vials, multiple pen 
packs. We've brought it down to----
    Mr. Pallone. All right. What would be the problem if the 
Government lists the price and just brings it down and says 
that is what you have to charge?
    Mr. Mason. I mean right now we have--the competition is 
fierce. I mean our net prices are lower today than----
    Mr. Pallone. So you think competition is working; the 
marketplace is working.
    Mr. Mason. I think it's working, yes. Yes.
    Mr. Pallone. I don't hear that from my constituents.
    Mr. Langa, it is unconscionable that these essential drugs 
have seen dramatic price increases. Why isn't Novo Nordisk 
reducing its list price? Again, my constituents say force them 
do it.
    Mr. Langa. Well, we do believe in a market-based system. I 
would also say if we reduced our list price, we would put all 
of our formulary positions in jeopardy. Just here at the table, 
these three PBMs represent 220 million covered lives, and for 
us the risk that----
    Mr. Pallone. So you are going to blame the PBMs again.
    Mr. Langa. It's not the blame. We don't want to put those 
lives at risk, but we are willing to----
    Mr. Pallone. All right, so then let's get rid of the PBMs 
and we will just set the price, the Government will set the 
price and you don't have to worry about the PBMs. What do you 
think?
    Mr. Langa. It's not what we believe in. We take a market-
based approach and it is competitive.
    Mr. Pallone. I agree with you, but nobody thinks it is 
competitive anymore.
    Mr. Langa. So if you look at our rebates, the average 
rebate for Novo Nordisk in 2014 was 48 percent. The average 
rebate just 4 years later in 2018 was 68 percent. That's a 40 
percent increase. We spent up to $18 billion last year in 
rebates, discounts, and fees to provide formulary access, so.
    Mr. Pallone. All right, let me--I think you are just 
passing it on to the PBMs.
    Ms. Tregoning, same question is people being forced to 
ration their insulin because they can't afford it. What is 
stopping Sanofi from lowering its list price? Why don't we just 
set the price ourselves?
    Ms. Tregoning. Congressman, unfortunately, under the 
current system simply lowering list price as I believe some of 
the witnesses last week attested to might not help patients and 
actually could cause some patients, who are on their 
formularies where we've secured position with rebates, to lose 
access. If we could get----
    Mr. Pallone. But if we set the price there would be no PBMs 
anymore.
    Ms. Tregoning. Congressman, I believe that the market-based 
system is very important for continued innovations. We don't--
--
    Mr. Pallone. I agree, but you guys have got to convince us 
that it is working and that the, you know, the problem that we 
have is we always end up having to interfere with the market 
when it becomes monopolistic, when it is not working, and my 
constituents say it is not working. ``What are you doing, 
Pallone? It is not working.''
    Ms. Tregoning. Congressman, competition is working. The net 
prices are coming down. The issue we have is that the results 
of that negotiation are not finding their way to patients, and 
that's the issue at hand. We at Sanofi are working, where 
patients are exposed to those high list costs, we are 
effectively de facto having a lower list price and covering 
through copay assistance or VALyou Savings Programs. But we 
don't control the out-of-pocket costs.
    Mr. Pallone. I mean the problem is, Madam Chair, I know my 
time is up, but everybody just blames, you know, the PBMs blame 
the companies, the companies blame the PBMs, and our 
constituents say they are all no good, just get rid of the 
system. I am reluctant to do that because I believe in a 
market-based system. But this is, you know, this is what I 
hear. Thank you.
    Ms. DeGette. Thank you, Mr. Chairman.
     The Chair now recognizes Mrs. Brooks from Indiana, for 5 
minutes.
    Mrs. Brooks. Thank you, Madam Chairwoman.
    I think everyone is focused and the answers all seem to be 
focused on the system which I think we all are acknowledging 
and are very frustrated. It seems to be very broken. In the 
February 6th letter that we sent to the manufacturers we heard 
it is becoming increasingly common for insurers and PBMs to 
only offer one insulin manufacturers' line on their 
formularies.
    I want to ask some questions about formularies and because 
it sounds like everyone in this finger pointing is having to do 
with formularies. And so, I am curious, why are, and not, you 
know, being involved in, but we are all learning a lot more 
about this system, why is it that you might have one insulin on 
a formulary? Why wouldn't you want all of them to be on your 
formularies?
    I also have a question because if you are, say, an 
employee's daughter or son and you are used to one insulin then 
the company switches their insurance program and then that 
child has to go to different insulin, why would we not offer as 
many options as possible?
    I will start with you, Dr. Dutta. If you could, you know, 
why do we make this change and then the rebates get in the 
middle of it and the discounts, and can you just help us? The 
system seems really broken and it sounds like that is part of 
it.
    Dr. Dutta. Thank you for the question. The first assessment 
is purely clinical. It is about whether a product is unique or 
if there are therapeutic alternatives. So when you have a 
unique product, price is high. It's put on our formulary, there 
is no competition. Then as manufacturers produce more products 
that are therapeutically equivalent, in the case of insulins 
rapid-acting insulins, long-acting insulins, in a category then 
there's an opportunity when they're equivalent to negotiate 
price down off of list price. However, to your specific 
question, if there's a patient that requires a medication that 
is not our preferred product or not formulary, we offer a 
process for the patient and their doctor to request and provide 
rationale for their product. If there's a good reason like an 
allergy or something like that, then they would be allowed to 
have that product.
     Mrs. Brooks. Thank you.
    Ms. Bricker, what would happen in the market for you to 
stop, for you, not just your company, but all of the PBMs here, 
what would happen if you stopped excluding certain insulin 
products from the formularies, if you allowed all of them in 
the different categories of insulins as I understand, if you 
allowed all of them to compete and be on each of your 
formularies?
    Ms. Bricker. Yes, thank you for the question. We don't have 
one formulary. We have many, many, many formularies. The 
formulary that provides the greatest savings for our clients 
actually limits through exclusivity or exclusive placement 
insulin options. We do that because we're able to secure the 
deepest discount from the manufacturer once we award that 
placement. And so, they're offering discount in exchange for 
market share and in exchange for access.
    But to your point, we have other options and we believe 
that choice to our plans is critical and they absolutely can 
select formularies that have all insulin on the formulary.
    Mrs. Brooks. What if we removed exclusivity from 
formularies?
    Ms. Bricker. Prices would go up.
    Mrs. Brooks. Why do you believe prices would go up? Mr. 
Moriarty, why would prices go up if all of the companies were 
able to be a part of your formulary? Mr. Moriarty?
    Mr. Moriarty. Because the drug companies would not offer 
the discounts that currently exist in the system.
    Mrs. Brooks. And so, if we were to remove all exclusivity 
from formularies, Mr. Mason?
    Mr. Mason. You know, our rebates went up during the period 
were removed from kind of dual access to exclusive formularies. 
That's what caused the list prices to go up.
    Mrs. Brooks. Mr. Langa?
    Mr. Langa. Our rebates have been competitive for years. 
Year over, year over year they're competitive. We believe in 
choice, choice for the physician, and choice for the patient. 
Someone that--a physician should be able to use their clinical 
experience to make decisions, not a formulary.
    Mrs. Brooks. What if we got rid of rebates and discounts, 
Ms. Tregoning?
    Ms. Tregoning. We would support moving to a system in which 
you had fixed fees for PBMs and that we removed rebates. As 
long as patient access and affordability could be guaranteed, 
we would be more than happy to move to that system.
    Mrs. Brooks. Do you think if we had systems like that you 
all would lower your insulin prices that would be offered?
    Ms. Tregoning. If we could be assured that patient access 
and affordability would be maintained, we would certainly be 
willing to lower our list prices, if we moved away from a 
rebate system.
    Mrs. Brooks. Mr. Langa?
    Mr. Langa. Yes, we support the rebate rule and we also 
support that if as long as there's access and affordability we 
are open to that option.
    Mrs. Brooks. Mr. Mason?
    Mr. Mason. Same answer.
    Mrs. Brooks. Thank you. I yield back.
    Ms. DeGette. The Chair now recognizes the gentlelady from 
New Hampshire, Ms. Kuster, for 5 minutes.
    Ms. Kuster. Thank you.
    Thank you very much for your testimony today and as we 
unravel this whole process of rebates and volume discounts the 
high cost that patients and families are facing for insulin. In 
New Hampshire we have 121,000 Granite Staters, just give or 
take ten percent of our population, actually, have either type 
1 or type 2 diabetes. These are the people that I have in mind, 
the families that we have been hearing from.
    But I want to understand, the frustration that the diabetic 
Americans come not just from the dramatic increases in the out-
of-pocket costs, but the mind-numbing complexity of how the 
drugs are priced and a belief that insulin manufacturers and 
pharmacy benefit managers may have lost focus on who they are 
truly meant to be working for, the patient. So that is really 
where we are coming from is to try to understand as we unravel 
this.
    You have heard some of the ideas here, which I would 
imagine would be a dramatic change in the way you do business 
on certainly from the conversations I have had with the PBMs, 
but also from the manufacturers' point of view. I mean, I don't 
think anyone really comes to this with totally clean hands 
because you are chasing the profits of the quarterly earnings 
as well as anyone else.
    I think part of what is difficult for us to understand is 
these are medicines that have been around for a long, long, 
long time without a great deal of innovation, without a change 
in the chemistry and the medication itself. Maybe there has 
been a change I understand in the delivery mechanism, you know, 
maybe there is a medical device change in having a longer 
lasting impact on patients, and certainly for patient 
convenience and patient health that is important.
    But we are trying to get to the bottom of why this has gone 
up so much. It is one thing for us to consider that in a field 
of medicine that has dramatic new innovations and the R&D 
costs, but it is all the more complex for us to sort that out 
with something like insulin.
    I want to get at two areas, if I could. Just, Mr. Mason, 
what efforts would you recommend to Congress to improve price 
transparency for patients? You obviously have taken a stand on 
getting rid of rebates or those types of things, but what is it 
that should be happening in terms of the patient understanding 
the pricing?
    Mr. Mason. We're open for transparency to help patients. We 
think the biggest issue that we're hearing right now--we want 
the same thing. We're not defending the system, we're just 
explaining the system up here. We want reform. We want, you 
know, anything that provides better access to patients. The 
heart of what we're hearing from patients is those with high-
deductible plans, about half of those high-deductible plans 
will take the rebates that are given to them and they use those 
to afford chronic, or affordable care for those with chronic 
disease. About half of them decide to actually put that back 
and actually lower premiums for the general population.
    So what we hear and what you're probably hearing is for 
those individuals who are in those high-deductible plans where 
that employer has decided to say, ``I'm going to pick the plan 
design that gives me lower premiums,'' because they're 
prioritizing that. They're making that conscious plan decision 
and that leaves individuals with chronic medication paying this 
price. That is a gap in the system right now that is leading to 
what we're hearing the most from diabetes patients.
    Now we're providing now a stop-gap measure to buy all those 
people down to $95, but that's a short-term fix. Long-term 
fixes should really be focused on what can we do with these 
high-deductible plans so that they have affordable coverage 
from day one and that decision is universal.
    Ms. Kuster. So you would agree that there is a discount for 
volume purchasing, and are you saying they fall outside--and I 
can ask Ms. Bricker to explain this.
    But--well, let me go to you, Ms. Bricker. What he is 
saying, how do we get to transparency for the patient, and how 
do we get all the patients to benefit from a mechanism that 
makes sense to me that you have described which is a volume 
discount, essentially? That is what the rebates are.
    Ms. Bricker. A couple of things, if I may, so believe 
strongly in having real-time benefit check at the time of 
prescribing that the physician has at his or her fingertips, 
what product is covered under the formulary, and what it will 
cost the patient, absolutely critical to ensuring that there 
isn't friction at the counter. Transparency, also, to plan 
sponsors so that they fully understand the value that we've 
negotiated for them by way of rebates and discounts.
    And so of course we've got to continue to do more. We've, 
as mentioned previously, announced a program for $25 insulin 
for all of our commercial patients. But clearly where we're 
still faced with challenges in the Part D benefit and we are 
absolutely in support of continuing to modernize that benefit 
such that patients, you know, have caps and don't have, aren't 
exposed to these high list prices, essentially.
    Ms. Kuster. My time is up, but thank you.
    Ms. DeGette. Thank you. The gentleman from West Virginia is 
now recognized for 5 minutes.
    Mr. McKinley. Thank you, Madam Chairman. I apologize. I 
have been back at two other committee meetings going on, so I 
have missed some of your--but I heard enough of it.
    Mr. Langa, I probably would focus most of my remarks 
towards you on this. I was here, so just begin, for my records 
the only thing that we have some information that we were--a 
vial of insulin in '67 cost a dollar. If just the CPI went up 
$17, but yet your NovoLog is now with a list price of 237, not 
$17.
    So many times, when we have our meetings back in the 
district in our roundtable discussions they talk about how 
people in West Virginia, probably no different than around the 
country, having three and four hundred dollars a month. I just 
talked with that fellow this morning, he said he just wrote a 
check for a thousand dollars for his insulin in excess of his 
insurance.
    What I was hearing not only similar dollar increases like 
this, but I was hearing all of you say it was caused by 
innovation, in part by innovation. I am curious what kind of 
innovation have we implemented over the last few years that 
would cause such a drastic increase in the price of insulin, 
the innovation part of it? Because let me just, I am a strong, 
strong supporter of innovation, so help me out a little bit. 
Why is innovation causing the increase in price?
    Mr. Langa. Sure, so innovation is very important to us as 
an organization, we're an innovator company. I would tell you 
that what's most important, and I think it was mentioned 
earlier, is that we keep the patient in mind. Because even that 
word ``incremental,'' it's not incremental to patients.
    So when you think about going from 4 to 6 injections a day 
to one, if you think about being able to take a mealtime 
insulin at or right after you eat versus an hour to an hour and 
a half before, if you think about basal insulin or long-acting 
products today that give you the support of hypoglycemia, maybe 
the best way I could describe it is: we have patients that want 
to work for Novo Nordisk because of the mission that we're on 
to defeat diabetes, and we have these patients sometimes speak 
at our company meetings.
    Mr. McKinley. I am just trying to understand the innovation 
part of it.
    Mr. Langa. But I am going to, I think, get to it.
    Mr. McKinley. Please get to it because we have run out of--
I don't need someone to filibuster here on me.
    Mr. Langa. It's not filibustering, it's this individual 
talk about what he lives with; night terror. Night terror is 
something called low hypoglycemia at night and actually makes 
him do things that are out of what he normally does. And 
because he got on a product called Tresiba that reduces 
hypoglycemia 40 percent----
    Mr. McKinley. You are saying, you are saying the innovation 
that----
    Mr. Langa [continuing]. He has not had a night tremor 
since.
    Mr. McKinley. I am saying if--were prior to having the 
innovation that prices were lower, now they are skyrocketing up 
to 237. Can we just stop the innovation? If it worked before, 
why in the last five years through innovation we have gone from 
17 or $20 up? I don't want to go there, because as an engineer 
I believe very much in research and to do that, but if we are 
driving the price up--innovation is supposed to drive the price 
down, not up.
    I am really troubled with it. But I think it is----
    Mr. Langa. Innovation is for today, and tomorrow I think 
it's important because we're innovating for the future and the 
future of people living with diabetes. So it's a partnership 
with MIT. It's our partnerships with the University of 
California San Francisco.
    Mr. McKinley. I want to respond back to why that in the 
past, until the last few years that I am sure you were 
innovating back in the '70s and '80s, the innovation and it 
wasn't skyrocketing like it is right now. So it is just 
counterintuitive that why innovation is driving the price up 
now in the last few years.
    Let me go back to the list prices because I am not going 
to--we are going to run out of time. But I don't understand 
that--I come from the construction industry, but also in life I 
need to see some examples of why we have these list prices set 
up for discounts I have heard you talk about. If we don't have 
rising list prices for cars and appliances and construction 
material, why is it that pharmaceuticals are jazzing up the 
list price so they can offer discounts? Why is that unique to 
the pharmaceutical field?
    Mr. Langa. Again, I know you've heard a lot about this 
today, but it is about these misaligned incentives in the 
system. The higher the rebate--excuse me. The higher the list 
price, the higher the rebate.
    Mr. McKinley. Yes.
    Mr. Langa. The rebates are used within the system. And that 
is--and again, and those rebates don't get passed through to 
the people living with diabetes and that is there that lies the 
challenge.
    Mr. McKinley. Should we eliminate or discourage the 
rebates?
    Mr. Langa. Well, certainly we're supportive of the rebate 
rule, and we're supportive of the pass-through of those rebates 
to benefit patients, and we think that would be something that 
would be healthy for patients.
    Mr. McKinley. OK, I have run out of time. I am sorry. I 
yield back.
    Ms. DeGette. The Chair now recognizes the gentlelady from 
Florida for 5 minutes.
    Ms. Castor. Well, thank you, Chair DeGette for holding this 
hearing to tackle the skyrocketing insulin prices.
    I recently met with a family from back home in Tampa. Nine-
year-old Brooke and her father Todd explained to me how she was 
diagnosed when she was three days old in the hospital and how 
they have struggled with her diabetes since then. But it is not 
just--the big struggle hasn't really been on the health side. 
It has been with affording insulin and drugs. They have had to 
change their lifestyle a little bit and Todd told me at one 
point they had run out of insulin two weeks before the end of 
the month and had to borrow a vial from an adult friend of ours 
who was using Humalog and had numerous vials stockpiled.
    That is how, he said, ``That is how we do it now. We tell 
our endocrinologist that we use more insulin than we need in a 
month, so she writes prescriptions for slightly more than we 
use. Since the vials are good for two years, we have extra in 
case anything happens. At the end of the day, we count 
ourselves blessed that both my wife and I work, and our 
insurance sufficiently helps pay for all of Brooke's type 1 
diabetes supplies, but the beginning of the year is still very 
difficult until we pay our deductibles. We choose to pay more 
for our insurance out-of-pocket to make those deductibles.'' 
But he says, ``I cannot fathom how a family can choose to limit 
or ration insulin for their children. The system needs to be 
fixed.''
    Then I asked Brooke, I said, ``What would you as a 9-year-
old having to deal with this, what would you want me to ask?'' 
She says, ``Why do we have laws that protect kids' safety like 
bike helmets, seatbelts, and indoor smoking bans, but not laws 
that would allow them to get the medicines they need to stay 
alive?''
    So this, things have got to change. So let's start with 
manufacturers' list prices and how we get them under control. 
It seems to be that just about everyone in the supply chain 
except the patient is benefiting from increasing list prices.
    Mr. Mason, if rebates and fees tied to list price were to 
be restricted or eliminated, do we have any guarantee from Eli 
Lilly that prices would go down and patients would pay less?
    Mr. Mason. We would definitely consider it.
    Ms. Castor. Mr. Langa?
    Mr. Langa. Yes. We would consider that, yes.
    Ms. Castor. Is there a guarantee?
    Mr. Langa. Well, what's important to us again is that the 
majority of patients can have access at affordable pricing and 
as long as there was that in place then, yes, we would consider 
that.
    Ms. Castor. Ms. Tregoning?
    Ms. Tregoning. Yes, as long as we can ensure patient access 
and affordability in formularies then we would certainly lower 
list price with the elimination of rebates.
     Ms. Castor. OK. There is another hitch in the system here 
and that is kind of the gaming of charitable contributions. It 
has been reported that some manufacturers use the Patient 
Assistance Programs to reduce their own tax burden. That by 
donating drugs to these Patient Assistance Programs, the 
company is able to deduct the value of the donated drugs from 
its taxes.
    In 2015, I understand Lilly donated 408 million worth of 
drugs to the Lilly Cares Foundation. Mr. Mason, should 
manufacturers be able to benefit financially from the Patient 
Assistance Programs?
    Mr. Mason. We do it only to help patients. We don't want 
anyone not to afford----
    Ms. Castor. But boy, that is a big--408 million, then I 
would think we would see some commensurate reduction of the 
list price that would be tied to that.
    Mr. Mason. Our net prices are going down, and then what 
you're not seeing is we spent $108 million last year on savings 
offers that helped 525,000 people. Those aren't a tax write-
off. Those are----
    Ms. Castor. I think there is an issue here though with 
these kinds of charitable contributions. You seem to be 
benefiting on both sides and patients aren't.
    So turning to the PBMs, Ms. Bricker, if fees paid to PBMs 
and wholesalers are standardized and entirely delinked from the 
list price, what impact would it have on what the patient 
ultimately pays?
    Ms. Bricker. Over 50 percent of our clients receive all 
fees that are collected from manufacturers and 95 percent of 
all fees and discounts and rebates are passed on to our plan 
sponsors. And so, ultimately when you delink the fee from the 
list price, there really is nothing that prevents the 
manufacturer from continuing to increase the price.
    Ms. Castor. So, Mr. Dutta, the mission of PBMs is to get 
the lowest price possible for drugs for their clients, but that 
clearly isn't happening. How can we change the system to better 
align out-of-pocket patient cost to negotiate a net cost 
instead of the list prices?
    Dr. Dutta. Well, 76 percent of our members today either pay 
zero-dollar copay or most commonly a flat copay of $35. And for 
that other percentage that you're asking about that are on a 
coinsurance or a high-deductible plan we advocate for point-of-
sale rebates as well as preventive drug lists such that 
insulins would not apply to the deductible.
    Ms. Castor. I yield back my time, thank you.
    Ms. DeGette. Thank you. The Chair now recognizes Mr. Mullin 
for 5 minutes.
    Mr. Mullin. Thank you, Madam Chair, and thanks for holding 
this meeting. It is not too often we get together and actually 
agree on issues, but we are all talking about the same thing; 
and we are all scratching our head trying to figure out how we 
got to this point.
    Real quickly, I want to go back to what was just asked 
about YOUR tax advantage for taking the rebates. Is there a tax 
advantage for YOUR companies for those rebates, yes or no?
    Mr. Mason. No.
    Mr. Mullin. No.
    Mr. Langa. No.
    Ms. Tregoning. No.
    Mr. Mullin. Well, what about the charitable contributions? 
Is that not a tax advantage?
    Mr. Mason. We only give insulin and what people use.
    Mr. Mullin. Well, because if it is at $300, and I am just 
using generic numbers, if the list price is 300, you put your 
rebates in and you get it all the way down to 100, who absorbs 
those rebates?
    Mr. Mason. That's not why we're doing it. We're doing it 
for----
    Mr. Mullin. No, who absorbs those rebates?
    Mr. Mason. Those----
    Mr. Mullin. Who absorbs those rebates? Do you guys absorb 
those rebates? If you are giving the rebates and the list price 
is at $300, you are getting it to $100, who absorbs those 
rebates?
    Ms. Tregoning. The rebates go to the PBMs with whom----
    Mr. Mullin. It doesn't go to the patient though, right?
    Ms. Tregoning. That's based on the--that's the concern that 
we have.
    Mr. Mullin. Do you write that off as a charitable 
contribution?
    Ms. Tregoning. That's different than a charitable 
contribution. The free drug program which are run through 
Patient Assistance Programs----
    Mr. Mullin. OK.
    Ms. Tregoning [continuing]. That's different. That's 
providing free drug to patients below a certain income 
threshold. That's separate from rebate----
    Mr. Mullin. You know what Mr. Griffith asked back here in 
the back, the innovation--no, I am sorry--McKinley asked about 
the innovation. When you are talking about the innovation side 
of things, are you using insulin today to help pay for future 
drugs? Is that the innovation that you guys are using for 
research? Does the price of insulin help offset the cost of 
research for future drugs?
    Ms. Tregoning. Revenues from all of our business, in part, 
go back to fund research and development across all areas. For 
diabetes in the United States, I would point out our revenues 
have gone down.
    Mr. Mullin. But I can understand price. A lot of you guys 
come in and you talk to me in my office and you say, ``Look, 
the price of the drug is so we can recoup our cost to develop 
it. That was the cost so that is why it is set at where it is 
because we are trying to recoup the cost of it.'' I totally get 
that. You have got to recoup the cost especially when you start 
having patents that are going to run out and you need to recoup 
your costs in time.
    But the cost is already recouped in this, so you are using 
insulin today, the cost of insulin today to pay for future 
drugs that are outside of insulin; is that correct?
    Ms. Tregoning. We continue to invest in research----
    Mr. Mullin. That is why you are seeing it go up so much?
    Ms. Tregoning. No, because our revenues from diabetes are 
going down. The net prices are going down. Our revenues from--
--
    Mr. Mullin. But you don't have any costs associated with it 
because it has already been developed. It has already been paid 
for.
    Ms. Tregoning. But again, the revenues for Sanofi's 
diabetes business in the U.S.----
    Mr. Mullin. OK.
    Ms. Tregoning [continuing]. Have gone down by half over the 
last four years because net prices have gone down so 
dramatically.
    Mr. Mullin. I have some quick questions I need to get to. 
If a patient qualifies for YOUR programs, how much does it 
cost? How much does their insulin cost at that point?
    Mr. Langa. Patient assistance is free.
    Ms. Tregoning. For copay assistance they'll pay no more 
than a $10 copay.
    Mr. Mullin. OK.
    Ms. Tregoning. But if they qualify for the charitable then 
it is free drug.
    Mr. Mullin. OK.
    Mr. Mason. Patient assistance is free.
    Mr. Mullin. Is free.
    Ms. Bricker, with the Express Scripts you guys came up with 
no more than a $25 charge to customers. You just rolled that 
out recently, right? How long did it take you to develop that?
    Ms. Bricker. We've been working on it for a few months.
    Mr. Mullin. For a few months. Have the companies here on 
the panel, have they agreed to participate in that with you?
    Ms. Bricker. Yes, they have.
    Mr. Mullin. It took you two months to come up with that. 
How are you guys able to offer that?
    Ms. Bricker. In collaboration with the manufacturers as 
well as in collaboration with the plan sponsors.
    Mr. Mullin. When a patient qualifies for YOUR programs, how 
long do they typically stay on those Patient Assistance 
Programs? Either one.
    Mr. Langa. It varies. It varies, really, by patient 
program. So they have renewal periods, but it could be 1 year, 
3 years.
    Mr. Mullin. Do you know what average the patient stays on 
the program?
    Mr. Langa. I'd have to get back to you on the average. I 
don't know what that is.
    Ms. Tregoning. I don't have that information.
    Mr. Mullin. Mason?
    Mr. Mason. Our separate foundation does that, so we don't 
have that data.
    Mr. Mullin. OK, I will yield back.
    Thank you so much for your time.
    Ms. DeGette. Thank you. The Chair now recognizes the 
gentleman from New York, Congressman Tonko, 5 minutes.
    Mr. Tonko. Thank you, Madam Chairwoman.
    I would like to begin by asking our panel a number of 
simple yes or no questions. During our hearing last week, 
patient advocate Gail DeVore testified that against her 
doctor's orders she had rationed and diluted a bottle of 
insulin because she couldn't afford to pay the $346.99 it cost 
her per month. Are you aware of stories like Gail's, and we 
will start with you, Mr. Mason, and go across, but yes or no, 
are you aware?
    Mr. Mason. Yes.
    Mr. Langa. Yes, we are.
    Ms. Tregoning. Yes, we're aware.
    Mr. Moriarty. Yes.
    Ms. Bricker. Yes.
    Dr. Dutta. Yes.
    Mr. Tonko. Have any of you personally ever had to ration a 
vial of insulin?
    Mr. Mason. I have not.
    Mr. Langa. I have not personally.
    Ms. Tregoning. No, I have not.
    Mr. Moriarty. I have not.
    Ms. Bricker. I have not.
    Dr. Dutta. No, and no one should.
    Mr. Tonko. Similarly, I hear stories from my constituents 
frequently about the struggle to afford lifesaving medications 
including having to make tough choices about putting food on 
the table or simply buying medication. Have any of you ever 
personally had to choose between feeding your family or buying 
a life-sustaining medication?
    Why don't we start with you, Dr. Dutta, and go the opposite 
way?
    Dr. Dutta. No, and no American should.
    Ms. Bricker. No, I have not.
    Mr. Moriarty. I have not.
    Ms. Tregoning. No, I have not, and agree no one should.
    Mr. Langa. I have not and no one should.
    Mr. Mason. I have not and no one should.
    Mr. Tonko. In a broader sense, have any of you ever 
struggled to afford a medication that was recommended to you by 
your doctor?
    Mr. Mason. I have not.
    Mr. Langa. There once was a time when one of my children 
had to be on a growth hormone product and we were not able to 
get reimbursement. At that time, it was going to be several 
thousand dollars and that was going to be a challenge for us. 
So yes, there was a time in my life.
    Mr. Tonko. Thank you.
    Ms. Tregoning. I'm fortunate not to have faced that 
situation.
    Mr. Moriarty. I have not.
    Ms. Bricker. I have not personally, but yes, my family 
members have struggled.
    Dr. Dutta. No, I have not and no one should.
    Mr. Tonko. Well, I thank you for your candor. I want to be 
clear that I am not asking these questions as a gotcha moment, 
but as a reminder that we need to approach this issue with 
empathy and compassion. We never know what the person next to 
us might be going through. These stories we have all heard and 
are sharing today are from real people.
    Modern medicines like insulin save lives, but when we 
dangle these life-sustaining medications just out of reach from 
those who need them, we are engaging in a most cruel form of 
torture. According to Dr. Lipska's testimony last week, one in 
four individuals reported using less insulin than prescribed 
over the past year specifically because of cost. Let's put 
ourselves in their shoes for the day.
    We can get bogged down here in Washington with the blame 
game and talk about esoteric issues like rebates and list 
prices and Patient Assistance Programs, but the reality is that 
when I go this weekend back to my hometown to Amsterdam, New 
York, there will be people in my community that are in the 
hospital putting their lives at risk, because they are so 
desperate for this medication that they are priced out of that 
they deliberately let their blood sugar crash just so they can 
get free samples of insulin on their way out of the door. 
Regardless of where you pin the blame, the system as it exists 
now is horrendously broken; and the companies represented at 
the witness table are benefiting while patients across the 
country are losing. That is unacceptable and we need answers.
    Last week, in testimony before the committee we heard from 
the Endocrine Society that in 2017 expenditures for insulin in 
the United States reached some $15 billion. They also told us 
that three of the top ten medication costs were for a type of 
insulin. Where is all this money going?
    Let's start with you, Mr. Mason.
    Mr. Mason. Our net prices are going down. Why we hear so 
much of why people can't afford their insulin today, it's those 
individuals in about half the high-deductible plans that don't 
benefit from the rebates and have high out-of-pocket costs 
because the rebates are being used to buy down the premiums.
    Mr. Tonko. Do those net prices need to go down further?
    Mr. Mason. Our net prices are going down.
    Mr. Tonko. No, you said they are, but do they need to go 
down further? In order for people to--we hear about CEOs 
getting an increase in their salary and we--tell us, well, the 
response is our net prices are going down. Do they need to go 
down further or do we need to take from the CEO?
    Mr. Mason. All I'm saying is our net prices are going down. 
The price that plans pay, payers pay to get insulin is going 
down, but those costs are not being used to help people who 
have diabetes in about half of the high-deductible plans. Those 
rebates are used in order to buy down premiums for the general 
population leaving those with chronic medications like insulin 
exposed to a deductible. That's what we're hearing. That's the 
point that we need to focus on solutions. That's the gap in the 
current system. The current system's not working. We agree a 
hundred percent. That is the heart of the issue.
    Mr. Tonko. Well, I see my time is up, I will yield back. 
But again a crisis that we need to resolve as soon as possible, 
quickly here. Thank you and I yield back.
    Ms. DeGette. The Chair now recognizes the gentlelady from 
New York, Ms. Clarke, for 5 minutes.
    Ms. Clarke. Thank you very much, Madam Chair, and I thank 
our ranking member. This is a very important hearing today and 
I wanted to ask a couple of questions.
    We have heard a number of examples of the dramatic rise of 
insulin prices this afternoon and I am still not clear on the 
flow chart. You know, we have heard a whole lot of different 
things about net pricing, list pricing, and that net pricing is 
going down.
    Is that what you are saying, Mr. Mason? OK, now is that 
subject to ebbs and flows? In other words, if you are saying 
that price is going down as we sit here, is there a point where 
that price gets settled at a lower price or is there the 
possibility that it rises again? Is it like oil?
    Mr. Mason. No, it's not like oil. I mean this has been 
pretty flat over the last 10 years. We can provide the, I think 
we provided the data as part of our written testimony.
    Ms. Clarke. Well, how is it then if they are going down 
over the past 10 years that it is still unaffordable? That is 
the flow chart that I am talking about. If you are going down--
first of all, it spiked for some strange reason, I guess the 
change in the system or the, you know, modernization of the 
system that included this rebate, you know, shenanigan, because 
that is what it is at the end of the day, if you have a 100-
year-old product that increased in value because all of these 
other dynamics got involved and, you know, it is the same 
product.
    Can you give me a sense of what happens when you produce 
this product, what the cost is, and then how it gets to the 
point where the average American can't afford, who needs it, 
can't afford to access it? That is the crux of this for, I 
think, the listening public. Because we have talked about a lot 
of terms of art here, but Americans need to know how you got to 
where you are given what we know. Can you explain? Can you 
explain, or is there anyone on the panel that can explain it in 
layperson's terms?
    Ms. Tregoning. Congresswoman, first, the insulins of today 
are very different than the insulins of the past, so I think 
that's also very important to keep in mind. That the insulins 
today----
    Ms. Clarke. We understand that.
    Ms. Tregoning. In terms of the list versus net prices, the 
net prices have been going down steadily. We talked about our 
insulins. Our list price has gone down 25 percent over the last 
five years, or since 2012, and that is expected to continue. 
The issue here is that the savings----
    Ms. Clarke. What precipitated that?
    Ms. Tregoning. It's additional competition and rebating----
    Ms. Clarke. Are you sure it wasn't the outcry of the public 
that could no longer afford it that are watering down their 
insulin?
    Ms. Tregoning. Unfortunately, Congresswoman, the lower net 
prices are not finding their way to patients, exactly to your 
point. That the rebates that exist in the system that gap 
between the list and the net prices is being used to subsidize 
other parts of the system and so, unfortunately, patients----
    Ms. Clarke. So the system became far more complex over 
time. Is that what you are----
    Ms. Tregoning. I think the system became complex and 
rebates generated through negotiations with PBMs are being used 
to finance other parts of the healthcare system and not to 
lower prices to the patient.
    Ms. Clarke. If we extract rebates from the system, what 
happens?
    Ms. Tregoning. If we moved to a system of fixed fee, we 
support the rebate rule then we would be able to lower our list 
prices, but we would need to ensure that the formulary 
position----
    Ms. Clarke. No. I just want to know if we removed the 
rebates.
    Ms. Bricker, I think you had----
    Ms. Bricker. If you remove the rebates, the discounts, 
there is no one that's advocating then for the patient and the 
plan sponsor to drive discounts and affordability. The rebates 
are discounts. They sound mysterious. It's just a discount and 
it's a volume discount.
    Ms. Clarke. Right.
    Ms. Bricker. And so PBMs serve a critical function in 
ensuring affordability. Are there people that slip through the 
cracks? Absolutely, and we're absolutely committed to figuring 
out how to serve each and every patient. But I would caution, 
doing away with rebates will only increase costs.
    Ms. Clarke. OK.
    Ms. Tregoning. We support having rebates pass through to 
patients, pass through to the patients who use the drugs upon 
which the rebates have been negotiated. That's----
    Ms. Clarke. This is a circular issue, because you want that 
passed on to the patient.
    Mr. Langa. Yes.
    Ms. Clarke. So that you can continue to push up the price.
    Ms. Tregoning. We don't receive list price. We receive the 
net price. We don't receive the list price.
    Ms. Clarke. You don't receive the list price.
    Ms. Tregoning. No. The price that is paid to manufacturers 
is ultimately the net price.
    Ms. Clarke. Right.
    Ms. Tregoning. So the rebates now are being used to offset 
other costs in the system. What Sanofi would advocate for is 
ensuring that those rebates are provided to patients who are 
using the drugs; upon which those rebates are negotiated to 
lower their out-of-pocket costs.
    Ms. Clarke. Are you saying that the PBMs' demand for 
increased rebates is the reason you are forced to keep raising 
your list prices?
    Ms. Tregoning. It is one component of how we consider and 
at Sanofi we have limited our list price increases. But one 
component of that decisionmaking is the dynamics of the supply 
chain.
    Ms. Clarke. What are the other components?
    Ms. Tregoning. The other components include the need to 
continue to invest in R&D and the competitive environment.
    Ms. Clarke. I yield back. I think it is more P&G. That is 
profit and greed. I yield back, Madam Chair.
    Ms. DeGette. The Chair now recognizes the gentleman from 
Maryland, Mr. Sarbanes, for 5 minutes.
    Mr. Sarbanes. Thank you.
    Is the rebate, Ms. Bricker, is the rebate system 
transparent right now would you say?
    Ms. Bricker. The rebate system is 100 percent transparent 
to the plan sponsors and the customers that we service. To the 
people that hire us, employers of America, the Government, 
health plans, what we negotiate for them is transparent to 
them.
    Mr. Sarbanes. So we can track the list price, then we can 
see the rebate, then we can see the net price, then we can see 
the savings that you pass along to the consumer; that is all 
completely transparent to the public?
    Ms. Bricker. It's not transparent to the public unless they 
are our patient.
    Mr. Sarbanes. Should it be?
    Ms. Bricker. We don't believe so.
    Mr. Sarbanes. Should it be a trade secret, is that the 
problem, like proprietary----
    Ms. Bricker. The reason I'm able to get the discounts that 
I can from the manufacturer is because it's confidential.
    Mr. Sarbanes. It is a secret.
    Ms. Bricker. Because it's confidential.
    Mr. Sarbanes. Yes, because it is a secret. What about if we 
made it completely transparent? Who would be for that?
    Ms. Tregoning. We would support transparency along the 
entire chain. That's the important thing is if we have 
transparency all along from the list price all the way through 
to patients.
    Mr. Sarbanes. Do you all support that?
    Ms. Bricker. Absolutely not, but----
    Mr. Sarbanes. No, you can't, because then it will end up 
hurting the consumer.
    Ms. Bricker. It will hurt the consumer.
    Mr. Sarbanes. Yes, it will hurt the consumer to have 
transparency, you know?
    Ms. Bricker. It will hurt the consumer, Congressman, 
because----
    Mr. Sarbanes. I don't buy it.
    Ms. Bricker [continuing]. Prices will be held high.
    Mr. Sarbanes. I am not buying it. I think a system has been 
built that allows for gaming to go on and you have all got your 
talking points.
    Ms. Tregoning, you have said you want to guarantee patient 
access and affordability at least ten times, which is great, 
but there is a collaboration going on here. I know there is 
this going on too, but the system is working for both of you at 
the expense of the patient.
    Now I reserve most of my frustration for the moment in this 
setting for the PBMs, because I think the lack of transparency 
is allowing for a lot of manipulation. I think the rebate 
system is totally screwed up, that without transparency there 
is opportunity for a lot of hocus-pocus to go on with the 
rebates. Because the list price ends up being unreal in certain 
ways except to the extent that it leaves certain patients 
holding the bag, then the rebate is negotiated, but we don't 
know exactly what happens when the rebate is exchanged in terms 
of who ultimately benefits from that.
    I think we need more transparency and I do not buy the 
argument that the patient is going to be worse off, the 
consumer is going to be worse off if we have absolute 
transparency. I think just to get the lobbyists in the room to 
shudder a little bit, I think the PBMs should be utilities or 
converted to nonprofits or something. I know when you started 
out, I understand what the mission was originally with the 
PBMs. It is a complicated industry. You need an intermediary to 
assemble all the information on both sides, to weigh in, to 
assemble the bargaining position so that you can get the best 
price, and in the early days that was a good argument.
    But now things have gotten out of control. You are too big, 
and the lack of transparency allows you to manipulate the 
system at the expense of the patient. I don't buy the argument 
that the patient and consumer is going to get hurt if we have 
absolute transparency. If we can't get it from a for-profit 
entity like the PBM, then we ought to look at other ways of 
doing it, including having the Government get into this space 
and compete in providing that important function. With that I 
will yield back my time.
    Ms. DeGette. The Chair now recognizes the gentlelady from 
Illinois, Ms. Schakowsky, for 5 minutes.
    Ms. Schakowsky. Thank you, Madam Chair, for holding this 
hearing.
    I don't know if I have any questions at all, but I want to 
tell you something. In the 2018 election, the number one 
concern of Americans, the high cost of prescription drugs. We 
have the names of people who have died because they couldn't 
get their insulin. A young man who was trying to control it 
himself after going off his parents' policy, dead. We know that 
a huge number of people are not taking the insulin that they 
need because they can't afford it. So then they get sick, they 
get sicker, and maybe they die because of it. I don't know how 
you people sleep at night.
    Between 1996 and now, when you have Eli Lilly from $21 a 
vial to $275, you heard Mr. McKinley--am I saying that right--
who went through all that, interesting by the way. So for Eli 
Lilly it is now $275. For Sanofi it is $270. For Novo Nordisk 
it is $280. Curiously close in price and way too high. I want 
to tell you something. That will not stand in this Congress. I 
heard Ms. Brooks say the system is broken and I think on both 
sides of the aisle there is a commitment. We have even heard 
the President of the United States talk about price gouging. 
Yes, we need transparency. I have a strong transparency bill 
that is going to hold you guys accountable and make you notify 
how you justify raising those prices. You talked about 
another--Mr. Langa, you talked about another drug that you are 
developing and that somehow that is an excuse because it helps 
diabetics and that is the research and development that you do. 
You are in trouble. And the lobbyists out here, or maybe that 
is you, need to understand that this is a commitment on the 
part of the Congress to get drug prices, particularly 
lifesaving, life necessities, to get those prices under 
control. If you think you can, you know, just out-talk us 
without any transparency, without any accountability, I just 
want you to know your days are numbered.
    You know, when Mr. Azar became the Secretary of Health and 
Human Services, I wanted to remind him that he came from Eli 
Lilly at the very time that those insulin prices went through 
the roof, and we are seeing that on drugs that have been like 
yours on the market for decades. If you want to try and 
explain--I totally agree, isn't that a good thing that now 
people may be able to take one vial and not have to shoot up 
all the time because, you know, and the delivery system. But we 
had no clue if that means that you can raise those prices a 
thousand percent.
    And you think you can get away with that kind of secrecy or 
just blaming the PBMs. I am not holding them unaccountable 
here, we need to do that. But don't excuse yourselves from this 
and don't tell us about the wonderful charity prices that you 
give and then you do get tax breaks, I am assuming--contradict 
me if I am wrong--when you give charity care to people. I 
believe that that is a tax-deductible kind of item for you, I 
am not hearing anybody contradict that. I resent that very 
much, because then everybody else is still paying those very, 
very high prices. So just know something is going to happen 
here if you don't decide in your own interests to lower those 
prices so people don't have to die. I yield back.
    Ms. DeGette. The gentlelady yields back. The gentleman from 
California, Mr. Peters, is recognized for 5 minutes.
    Mr. Peters. Thanks. I have heard a lot of this discussion 
and it has been very edifying for me. Actually, I don't want to 
blame you for a system that we have set up here that encourages 
these bizarre incentives. The fact is that it is a system that 
incentivizes people to charge higher list prices so they can 
give rebates that give them access to customers.
    I am pretty much a believer in markets. Someone called this 
a free market. This is really not. I don't think that we should 
suggest that this is the kind of competition that is going to 
take care of our problems. What we have here is what economists 
call a ``market failure'' at best. That is when it is 
appropriate for government to take action in a capitalist 
system. I think most people agree with that, and I think that 
is what we are going to see.
    We are going to have to take out the incentive, this crazy 
incentive to charge higher prices so that you can get the 
customers and no one knows what the real prices are. I mean it 
is impossible for us to understand, you know, we have access to 
all this information, this is a really, really opaque system 
and so we are going to have to change that.
    I appreciate the input. I don't ever suggest that companies 
aren't going to make money when they are allowed to do it. I 
just think that this is a perverse system that has to be 
changed so that if we want competition, we get real 
competition. But this system of rebates is really encouraging 
an anti-competitive behavior.
    Also, I know that--I will just express a concern and this 
is in the courts. But, you know, now we have companies owning 
PBMs and plans without any assurance of the relationship 
between the sister companies, the PBMs and the plans. Again, I 
think there is a real risk of anti-competitive behavior.
    I mean, I think you have come here and done the best job 
you can answering these questions. It is a system that no one 
should have to apologize for, but it is a system that we are 
going to have to change here in Congress; and I think that is 
what you will see going forward. I yield back.
    Ms. DeGette. The gentleman yields back.
    We now have several members who are not on this 
subcommittee but who have been gracious enough to be here for 
most of all of the hearing, and I appreciate their attendance 
and input. I would like to first recognize Congressman Bucshon 
for 5 minutes.
    Mr. Bucshon. Thank you, Madam Chairwoman.
    I was a physician before I was in Congress, so these types 
of issues are extremely important to me. For me it is all about 
people and taking care of people, making sure especially when 
it is a life-sustaining drug. I appreciate all of your input. 
It is a system that needs changed.
    We did a hearing last Congress and we had eight 
stakeholders in the entire supply chain and we pretty much got 
this, you know, the whole time, and I get that. I am not 
blaming anybody. I am just saying I think it is just, we have 
developed a system over time that is going to need changed. I 
am going to have questions for both the PBMs and the companies.
    Dr., is it Dutta, yes, I understand that representatives 
from your company testified in front of the Senate Finance 
Committee yesterday. My understanding is that your company was 
asked questions about contracting practices and relationships 
with manufacturers. I would like to just follow up on those and 
then Ms. Bricker and Mr. Moriarty can comment also.
    Can you talk about the following: Has your company ever 
proposed in contract or otherwise demanded that manufacturers 
give advance notice of list price decrease? I remind you, 
everybody, we are all under oath here, so, and we have access 
to information potentially that could counteract a questioned 
answer that isn't accurate.
    Dr. Dutta. Yes.
    Mr. Bucshon. OK. And then the manufacturers pay a higher 
fee, a rebate, if list prices do not increase above a certain 
percentage in that contract year? So, for example, if they 
don't increase their list price above a certain percent that 
they may have to pay a higher fee or rebate for that drug?
    Dr. Dutta. I'm not aware of that.
    Mr. Bucshon. OK. And that manufacturers pay a certain 
rebate amount even if they decrease their list price?
    Dr. Dutta. I'm not----
    Mr. Bucshon. My point is if you have a list price here and 
the company says, ``We are going to go down to here,'' and the 
rebate was based on the higher list price, does that amount 
stay the same?
    Dr. Dutta. I'm not aware of that.
    Mr. Bucshon. OK.
    Same questions, Ms. Bricker, is do you have contractual or 
otherwise demanded that manufacturers give advance notice of 
list price decrease?
    Ms. Bricker. No, we welcome lower list prices.
    Mr. Bucshon. OK, great. And that manufacturers pay a higher 
fee or rebate if list prices do not increase above a certain 
percentage in that contract year?
    Ms. Bricker. No.
    Mr. Bucshon. OK. The manufacturers pay a certain rebate 
even if they decrease their list?
    Ms. Bricker. No.
    Mr. Bucshon. OK. We hear that they do.
    But, Mr. Moriarty, same thing, I mean do you have 
contractual relationships that otherwise demand that the 
manufacturers give you advance notice of decrease in the list?
    Mr. Moriarty. No.
    Mr. Bucshon. OK, great. The manufacturers pay a higher fee 
or rebate if list prices do not increase above a certain 
percentage in a contract year?
    Mr. Moriarty. No.
    Mr. Bucshon. OK, great. The manufacturers pay a certain 
rebate amount even if they decrease the list?
    Mr. Moriarty. No.
    Mr. Bucshon. OK.
    Mr. Moriarty. We are all about net price.
    Mr. Bucshon. Understood.
    I am going to focus on the 340B program real quickly. I 
have been an advocate for reforming that program. Information 
that Novo Nordisk provided to the committee indicated that many 
of Novo Nordisk's insulin products are at penny pricing in the 
340B program. Moreover, information Novo Nordisk provided the 
committee showed that for one of these insulin products at 
penny pricing the number of packages provided to 340B entities 
increased from just over 270,000 packages in 2014 to over 
735,000 packages in 2018. That is more than 172 percent 
increase in the number of packages supplied to 340B entities, 
and many of the Novo Nordisk other insulin products also saw a 
significant increase in the number of packages sold in the 340B 
program during this period.
    Can you explain the impact that the 340B program has had on 
Novo Nordisk's pricing in the private and commercial markets?
    Mr. Langa. We have over 18,000 facilities, I believe, at 
this point roughly and it is at penny pricing. So it's 
literally 99.9 percent, and the packaging is, I believe as you 
reference it so; and has been going up. Is the question its 
influence on the commercial market?
    Mr. Bucshon. Yes, I mean because of that, because of its 
penny pricing and the volume has gone up dramatically, has that 
had an effect on the overall pricing structure in the rest of 
the marketplace, essentially?
    Mr. Langa. I think the challenge has been the 340B entities 
and who actually gets the designation and not. I think that's 
been more of the complexity and the challenge than it has been 
the spillover.
    Mr. Bucshon. OK.
    Mr. Mason, same thing. I mean 340B has dramatically 
expanded as we all know, right?
    Mr. Mason. A similar question, I mean obviously it does 
take away our net sales. If those are legitimately helping, you 
know, individuals that need that help we're fine that our 
product is going----
    Mr. Bucshon. I understand that. I mean, but, and quickly. I 
am out of time.
    Ms. Tregoning. Yes. I think the issue is the heavily 
discounted products that go into the 340B system. But are those 
heavily discounted prices making their way to patients.
    Mr. Bucshon. Yes. I am going to just quickly say, with your 
indulgence, Madam Chairwoman, that in the 340B program I firmly 
believe based on this subcommittee's report that was released 
last Congress that we need to seriously look at and reform the 
340B program; so that it continues to exist for the hospitals 
and patients that need it, but add a degree of transparency 
because it is spiraling.
    Thank you, I yield back.
    Ms. DeGette. I thank the gentleman. The Chair now 
recognizes the very, very patient woman from California, Ms. 
Barragan, for 5 minutes.
    Ms. Barragan. Thank you very much.
    You know, I am sitting here, and I have been hearing this 
back-and-forth for the last couple of hours, and the way I 
think I would summarize this is it sounds like we are playing a 
middleman. It just sounds like we are playing a middleman for 
prescription drugs to be on a preferred list. That is not just 
to put all the blame here, but then these list prices have just 
been skyrocketing and then when we ask about pricing. What we 
are hearing back from the drug companies is, well, the net 
price is actually declining. Last time I checked I think Lilly 
was doing pretty good. Wouldn't you say so, Mr. Mason? Why 
don't you tell me what the revenue was for this coming year? 
What is Lilly's revenue this coming year?
    Mr. Mason. $21 billion.
    Ms. Barragan. OK, I saw $25.3 billion for the coming year. 
Your CEO in 2014 was making 14.5 million in a pay package. That 
was in 2014. The new CEO, 2018, is making $17.2 million in a 
pay package. You guys are doing okay. I would think so. The 
American people sees that, and they say, ``Why can't we just 
get pricing for insulin, a lifesaving drug that we need? Not 
that we want, but that we need.'' And they say Congress has to 
do something.
    When you see what, when you hear what is happening here 
today that is exactly what is going to have to happen. I don't 
see anything happening here. I mean, look, I represent a 
congressional district that is a majority minority. People of 
color are disproportionately impacted by diabetes, Latinos and 
African Americans. I happen to represent a district that 
includes Compton and Watts, very low-income, working class 
families who are struggling. My report says there is over 
80,000 uninsured there, a lot of people who probably can't 
afford to pay for their insulin.
    Do you all recognize that YOUR pricing policies and this 
system is causing people to die every day? Do you all recognize 
that? Mr. Mason, do you recognize that? Let me just go down the 
list here, yes or no, do you all recognize this?
    Mr. Mason. We don't want anyone not to be able to provide 
their insulin. We----
    Ms. Barragan. I understand that. But do you recognize that 
this pricing system and model is causing people to die?
    Mr. Mason. We need to do something about it collectively.
    Ms. Barragan. OK, that is a yes.
    Mr. Langa?
    Mr. Langa. We recognize the model is certainly a challenge, 
yes.
    Ms. Barragan. You are playing a role in that model. Let's 
not mince any words here, is these companies and the PBMs are 
playing a role in this model and that is why we are having this 
hearing is because we are trying to get to the bottom of it.
    Ms. Barragan. Ms. Tregoning.
    Ms. Tregoning. Yes, we recognize that's happening and 
that's why we put in place the programs, to address the 
inadequacies of the current system so that that doesn't happen, 
so people aren't forced into rationing their insulin. We don't 
want to see that.
    Ms. Barragan. Mr. Moriarty?
    Mr. Moriarty. There's no question there's a portion of the 
population where this needs to be addressed very directly, no 
question.
    Ms. Barragan. Ms. Bricker?
    Ms. Bricker. Absolutely there are patients falling through 
the cracks. We exist only to make medication more affordable 
and----
    Ms. Barragan. OK. I am not obviously going to get you to 
tell me that you are a part, because I mean, and the reality is 
what we heard today that that is what is happening here. You 
know, I wish that you all would just come together and 
collaborate.
    A moment ago, Ms. Bricker, I believe you are the one who 
said that the way you were able to get the $25 plan and the 
deal that you were able to get for the insulin, the new program 
that you just rolled out, was that you collaborated together, 
that you worked together. So if you could do it there, how come 
you all can't do it for others, right? And so, this is where 
Congress has to step in and do something. It is because of 
profits. It is because of greed. The American people are tired. 
And when people die, when people die and that is what is 
happening, make no mistake about it, we hear about it. The 
country hears about it and it is outrageous. It is completely 
outrageous.
    I want to end quickly on the Medicare Part D. You know, in 
2018, more than 43 million seniors enrolled in Part D plans. 
Currently, the Government is prohibited from negotiating 
directly with the drug manufacturers on behalf of Medicare Part 
D enrollees. If this prohibition were lifted the Government 
would be able to provide the leverage needed to bring down 
prescription drug pricing.
    On a yes or no real quick because I only have 10 seconds, 
starting on the end, yes or no, do you support Medicare being 
able to negotiate drug prices under Part D?
    Mr. Mason. Prices are getting better in Part D----
    Ms. Barragan. Yes or no, would you support negotiating drug 
prices under Medicare Part D?
    Mr. Mason. Just don't think they're needed.
    Ms. Barragan. OK.
    Mr. Langa. I think everything we would consider, if it 
helped the patient.
    Ms. Barragan. So that is a yes?
    Mr. Langa. I think we'd consider everything. I think the 
fair market, the free market that's playing right now is 
working because we have some of the heaviest discounts in Part 
D.
    Ms. Barragan. It is not working because people are dying, 
and they can't afford it.
    But next?
    Ms. Tregoning. The PBMs are very effective negotiators. The 
question: is what do we do with the results of those 
negotiations?
    Ms. Barragan. You don't have an answer on whether you 
support Medicare being able to negotiate drug prices under Part 
D?
    Ms. Tregoning. Don't support direct negotiation because the 
PBMs are effective negotiators.
    Ms. Barragan. You do not. OK.
    Mr. Moriarty. We do not. We drive very effective 
discounting.
    Ms. Barragan. OK.
    OK, Ms. Bricker?
    Ms. Bricker. Similarly, yes. The Government----
    Ms. Barragan. You do not?
    Ms. Bricker. Do not support.
    Ms. Barragan. OK.
    Mr. Dutta?
    Dr. Dutta. We do not.
    Ms. Barragan. OK. I can understand why that might be the 
case. It is unfortunate, but my time is up. I yield back.
    Ms. DeGette. Thank you. I thank the gentlelady.
    I am now pleased to recognize the gentleman from Georgia, 
Mr. Carter, for 5 minutes.
    Mr. Carter. Thank you, Madam Chair, and thank you for 
allowing me to participate in this.
    Ladies and gentlemen, thank you for being here today. Just 
a full disclosure, currently I am the only pharmacist serving 
in Congress. I practiced pharmacy, community pharmacy, 
independent community pharmacy for over 30 years. You know, I 
remember and just FYI, I started when I was ten. But I can 
remember that--I can remember when PBMs evolved. I can remember 
when PSC was nothing more than a processor. That is all they 
did was process claims before PBMs got involved in setting up 
formularies. I can remember ordering directly from drug 
companies and not going through a wholesaler or anyone, just 
getting a shipment every week, a delivery every week from Eli 
Lilly or any other of the companies, Upjohn, or any of the 
number of companies that we ordered from.
    You know, my colleague, Mr. Tonko, mentioned earlier about 
patients having to make choices between eating and between 
paying for their medications. I have seen it firsthand. I have 
witnessed it firsthand.
    Ms. Bricker, you said you were a pharmacist and practiced 
in community forums. I don't know what your experiences were. 
You are obviously a lot younger than me, but at the same time I 
can tell you I have seen it. I have seen patients at the 
counter having to make a decision between buying medicine and 
between buying groceries. I have seen mothers in tears because 
they couldn't afford their medications. I have witnessed it 
firsthand. I was the boots on the ground there. That is why I 
am so passionate about that.
    I wanted to start with you Mr. Langa. During a briefing 
with committee staff, I don't know if it was you or a member, 
or a representative of your company; but they said that list 
prices started to increase more rapidly around the same time 
that there started to be more consolidation throughout the drug 
pricing supply chain, and that there have been increasing 
demands on rebates. Has consolidation impacted the list price 
of medications?
    Mr. Langa. I think it was a factor. I think that as the 
PBMs today, as I mentioned the three here today represent 
almost 220 million covered lives or 80 percent of the lives, 
so.
    Mr. Carter. And that is probably, the three here today I 
believe represent over between 70 and 80 percent of all the 
PBMs in America.
    Mr. Langa. Correct. I think that as the consolidation that 
purchasing power got bigger, the rebate challenges got heavier.
    Mr. Carter. Absolutely.
    Mr. Mason, would you agree with that? And in fact, I 
believe that you responded to a letter and said the same thing.
    Mr. Mason. Yes.
    Mr. Carter. OK.
    I would like to ask you, Mr. Moriarty, you are with CVS 
Health. CVS is a drugstore, right?
    Mr. Moriarty. That's correct.
    Mr. Carter. Caremark is the PBM.
    Mr. Moriarty. That's correct.
    Mr. Carter. And that is owned by CVS, the same company?
    Mr. Moriarty. That's correct.
    Mr. Carter. Aetna Insurance is the same company?
    Mr. Moriarty. That's correct.
    Mr. Carter. OK, so we got Aetna the insurance company, we 
got Caremark the PBM, and we got CVS the drugstore, all the 
same company, right?
    Mr. Moriarty. That's correct.
    Mr. Carter. OK.
    Ms. Bricker, I believe that Express Scripts, you are here 
today representing the PBM?
    Ms. Bricker. Yes, I am.
    Mr. Carter. You are also--you just bought out CIGNA 
Insurance. That is right?
    Ms. Bricker. CIGNA acquired Express Scripts.
    Mr. Carter. CIGNA acquired Express Scripts, and you also 
have your own mail-order pharmacy; is that correct?
    Ms. Bricker. We do have a mail-order pharmacy.
    Mr. Carter. OK.
    Dr. Dutta, same thing with you. Optum is the PBM, United 
Healthcare is the insurance company, and you also have your own 
mail-order pharmacy; is that correct?
    Dr. Dutta. Optum and United Healthcare are sister 
companies, yes.
    Mr. Carter. You do have a mail-order pharmacy that you own 
as well?
    Dr. Dutta. OptumRx has a mail-order pharmacy.
    Mr. Carter. Yes. okay, that is a long yes answer. 
Nevertheless, when you have been saying during these hearings 
that you are returning money to the plan sponsors, can you 
define plan sponsors for me? Is that the insurance companies?
    Mr. Moriarty?
    Mr. Moriarty. It is the employers, State and Federal----
    Mr. Carter. The insurance, are you sending the money back 
to the insurance company?
    Mr. Moriarty. As well as health plans, but it's much more 
than just health plans. Yes, sir.
    Mr. Carter. You are sending it back to--and, Ms. Bricker, 
you are sending it back to the insurance companies?
    Ms. Bricker. So we send back to the clients that hire us. 
Those are employers----
    Mr. Carter. At the end do you send it back to the 
insurance--please remember you are under oath here. Let's get 
on. Do you send it back to the insurance companies?
    Ms. Bricker. In the event that the plan sponsor is an 
insurance company, yes.
    Mr. Carter. Right.
    Ms. Bricker. But that's not the only----
    Mr. Carter. OK.
    Dr. Dutta, same thing with you?
    Dr. Dutta. In the event that the plan sponsor is the 
insurance----
    Mr. Carter. OK, same thing. So essentially you are the PBM 
managing money and you are sending the money back to another 
company that you own. In some cases that could be the case; 
isn't that right, Dr. Dutta?
    Dr. Dutta. So we have many health plans that----
    Mr. Carter. I understand that. But it is possible you could 
be sending it back to the--owned by the same company. So this 
vertical integration that we are talking about here that I have 
been on the FTC and the Department of Justice about, that is 
something that certainly we need to be aware of.
    Boy, 5 minutes flies, let me tell you. But before I 
relinquish my time, I want to congratulate all of you because 
you have done something here today that we have been trying to 
do in Congress ever since the 4 years and 3 months that I have 
been here and that is to create bipartisanship, because what 
you have witnessed here today is bipartisanship.
    This is going to end. I have witnessed it. I have seen what 
you have done with the PBMs. I have seen what you have done 
with DIR fees. I see what you are trying to do now with GER 
fees and BER fees. Let me tell you, what the CMS is proposing 
in the way of doing away with DIR fees and the way of having 
discounts at the point of sale, that is going to happen. We are 
going to make sure that happens and that is going to bring more 
transparency to the system, and we are not going to stop there.
    Thank you, Madam Chair, and I yield back.
    Ms. DeGette. Thank you, Mr. Carter. I was just saying I 
never thought I would see the day when Buddy Carter was 
channeling Jan Schakowsky. Congratulations.
    I now want to recognize Mr. Guthrie for closing questions 
and a statement.
    Mr. Guthrie. I just want to close and when the Chair and I 
were discussing having the hearing we thought insulin was a 
proper one to have. One, I know it is different than 100 years 
ago today. But we had a lady before, a doctor, physician from 
Yale that said that there was--held up an insulin and said this 
is the same insulin from the 1990s as it is today and the price 
has moved forward.
    We wanted to--because we wanted to look at the entire 
system, but we thought if we looked at one drug that affects 
almost--like I said, I have two nieces with diabetes--it 
affects almost every family, that we could look at what is 
going on and then we could extrapolate to bigger.
    I will tell you, and you were talking about Ms. Schakowsky, 
my friend Ms. Schakowsky from Illinois, she also talked about 
President Trump in saying that this is important to him. My 
experience with him in meeting with him is that drug pricing is 
important to him, so it is everybody. It is uniting everyone.
    I am going to be quick. I know 5 minutes went fast before, 
I didn't get all my questions. I am not going to ask a question 
because that is not what I have been recognized for. But 
innovation is important. I saw a film yesterday of a father 
talking about his daughter, I don't know if ``cured'' is the 
right word, but not having any symptoms from sickle cell. I 
mean it is just--Hepatitis C, you can take with, and you talk 
about medical devices. You can do the artificial pancreases 
here.
    So innovation and having a market-based system and a free 
enterprise system is absolutely important and--but what we are 
trying to get at with this is, and hopefully you can see our 
frustration, is that we see the pharmaceutical companies say, 
``Our net price is going down.'' We see the list price going 
up. I have friends here from Bardstown that are in the Buddy 
Carter situation, are community pharmacists, and they see, have 
described to me situations that he just described and they have 
to pay the list price to sell to somebody who is not through 
the--when they sell, so it is a cash flow to those kind of 
businesses.
    What we are trying to figure out is if the net price is the 
net price, then why isn't that what is paid to the--if the idea 
is we are going to get the lowest price for our insurance 
companies, then why isn't selling something for $135 that is 
costing them $135 better than selling something 300 or $400 and 
getting 300 or $400 back, other than saying I saved you that 
money? Just trying to figure out where the money is going and 
so this has been informative.
    I think one question I wanted to ask that I am going to do 
for the record is, so what you put on the formulary, is it 
better for a high list price with a lower net or that is better 
for the insurance company, but it is not as good for a--if it 
is just a lower net price or just lower list price, it is 
actually lower for the consumer going to the counter at the 
pharmacy?
    This is just hopefully the beginning of a series of 
hearings and it has been informative. We do appreciate you 
willing to come here and your testimony and trying to inform us 
because we do have to make some decisions. We don't want 
unintended consequences because you could get into--if you get 
into price controls you get into rationing and you get into 
shortages and that is not where we want to--that is not where I 
want to go. We want people to have a fair price that they can 
pay and if they can't pay to have the assistance to have that 
because it is lifesaving.
    Thank you for your indulgence and I yield back.
    Ms. DeGette. I thank the ranking member, and I do want to 
thank the witnesses. I know people asked you hard questions. It 
was important to us to get everybody in here, and I think we 
can all agree that the system is broken, and it has grown up in 
a way over time that people didn't anticipate. But here is the 
thing. The people who are suffering are the patients. In the 
case of insulin, the people who are suffering are people who 
need insulin every second of every minute of every day or they 
will die, and that is the issue that we have here.
    I now, having done this investigation last year with my 
colleague from New York, Tom Reed, and now doing this 
investigation, I think I have a pretty good grip, and I think 
the members of this committee are getting a better and better 
grip of what is going on. And what is going on is the system 
has grown up in this country where we are continually--it is a 
smoke-and-mirror system where we are continually increasing the 
list price of insulin in order to try to do negotiations to 
somehow get the price of insulin down.
    But let's look at the reality of the situation. The members 
of this panel kept saying over and over again net prices of 
insulin have gone down and one person even said that nobody 
pays list price, they all pay net price. But that is not 
exactly true.
    So I just want to give you the example of Humalog, because 
Humalog is one of those insulins, it is not 100 years old, but 
it is over 20 years old and in 2001, Humalog cost $35 a vial. 
Today, no change to Humalog--it is not Tresiba, which by the 
way Tresiba is not an insulin, it is another drug to help 
absorption of insulin that is given to type 2 diabetics--so 
Humalog, it is still the same formulary. It is $275 today for a 
bottle of the same insulin that I bought for Francesca when she 
was six years old, and the generic Humalog that Lilly has come 
up with, good news, it is only $137 a bottle. So it is still 
way beyond where it was in 2001.
    Well, now Sanofi has a new generic alternative, Admelog. I 
just sat here and looked and Admelog, it might not cost as much 
as Humalog, but it costs over $200 a bottle. So let's not kid 
ourselves that the generic equivalent of this is really any 
cheaper for that young woman in my district who doesn't have 
insurance who is desperately trying to find two bottles of 
insulin every month. That is $400 for her even if she bought 
that.
    When you say nobody is paying list price, there are people 
paying list price. The people who are paying list price are the 
people who have high-deductible plans who have to pay for the 
list price when they go in to the pharmacy and they are on 
their deductible, the people who are in the doughnut hole of 
Medicare Part D, and the people who are uninsured.
    I know all of the, everybody here, the PBMs and the 
pharmaceutical companies all have these efforts to give cheaper 
insulin to people like this, but I am going to tell you, the 
lady I talked to in Denver, she didn't know how to get that 
insulin. She had no idea how to get it, and our witnesses last 
week said many people in that situation don't. It is not a 
solution to the problem, it is just a temporary Band-aid and it 
is one that we have to stop with a wholesale innovation.
    Let me just say, finally, this. It is not like the 
pharmaceutical companies or anybody else in the system is doing 
this for a public interest reason. The pharmaceutical companies 
had $323 billion in profits last year. The PBMs had $23 billion 
in profits last year. And so everybody is making a profit and 
the people who are really suffering here are the people who 
either have to pay list price or even after their deductible 
have to pay an unacceptable price and nobody here in this room 
wants that.
    What we are going to do, we are going to get together in a 
bipartisan way and we are going to work with all of you, plus 
everybody else in the distribution center, to figure out how we 
can provide insulin to diabetics at a cost that they can afford 
and we are going to do that as quickly as we can. So as you 
heard we are having an ongoing investigation here. We are 
prepared to talk to you now and we are prepared to bring you 
all back in July or in September to talk about the progress 
that we have made, because this is not optional and it is going 
to happen. I want to thank you all again for coming today and 
we are not going to have any more testimony, but I really want 
to thank you for coming and I want to thank you for being part 
of the solution and not a continuing part of the problem.
    In closing, I will remind members that pursuant to 
committee rules they have 10 business days to submit additional 
questions for the record to be answered by witnesses who have 
appeared before the subcommittee. I ask that the witnesses 
agree to respond promptly to any such question should you 
receive any, and with that the subcommittee is adjourned.
    [Whereupon, at 2:37 p.m., the subcommittee was adjourned.]
    [The article appears at the conclusion of the hearing.]
    
    
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