Prescriptions and Reimbursement of Glucagon Products for Severe Hypoglycemia in Medicaid

Abstract

This study examines trends in prescribing and reimbursement for glucagon products in Medicaid before and after the introduction of these newer products.

Severe hypoglycemia resulted in 202 000 emergency department visits in 2020 for people with diabetes.¹ Glucagon is a rescue medication for severe hypoglycemia that can be administered outside health care settings. Professional guidelines recommend that all people with diabetes at risk of hypoglycemia (especially those taking insulin or a sulfonylurea) have access to glucagon.²

Despite these recommendations, glucagon fill rates are low.³ Traditionally available glucagon formulations require reconstitution prior to injection and, therefore, may be difficult to administer. Since 2019, newer glucagon products have been introduced, many of which are easier to use than reconstituted, injectable glucagon.⁴ This study examined trends in prescribing and reimbursement for glucagon products in Medicaid before and after the introduction of these newer products.

Methods

We used the Drugs@FDA Directory to obtain a list of national drug codes (NDCs) for all approved glucagon products. The NDCs from glucagon products not designated solely for the treatment of severe hypoglycemia were excluded. Each product was assigned to 1 of 5 categories based on formulation and route of administration (glucagon nasal spray, glucagon unmixed syringe, glucagon prefilled syringe, dasiglucagon auto-injector, and glucagon auto-injector). We obtained Medicaid State Drug Utilization Data on total reimbursement, the sum of reimbursements from both state Medicaid departments and other parties that pay part of Medicaid costs (eg, other federal coverage, co-pay, private insurance), and the number of prescriptions by quarter for each NDC from 2012 to 2023.

Data from Medicaid were chosen because Medicaid is one of the largest insurers of adults with diabetes in the US.⁵ Data were aggregated to calculate yearly totals. Reimbursement totals were adjusted for inflation to 2023 values using the Federal Reserve Bank of Minneapolis inflation calculator.⁶ We focused on the periods before (2012-2018) and after (2019-2023) the introduction of newer glucagon products (eg, intranasal and auto-injector formulations) in Medicaid. We used descriptive statistics to compare the 2 periods. The figures were created using R statistical software version 4.3.1 (R Foundation for Statistical Computing).

Results

Compared with the number of glucagon prescriptions in 2012 (78 505), the number in 2018 (56 722) decreased by 21 783 prescriptions (28%) (Figure 1). The annual total reimbursement increased by $7 086 119 (33%) between 2012 ($21 233 811) and 2018 ($28 319 930) (Figure 2). In 2018, unmixed syringes made up 100% of all 56 722 glucagon prescriptions. After the introduction of newer glucagon products, glucagon prescriptions increased by 34 894 (61%) between 2019 (56 838) and 2023 (91 732). The annual amount reimbursed increased by $14 279 600 (50%) between 2019 ($28 370 595) and 2023 ($42 650 195). During the same period, prescriptions for nasal spray formulations increased from 2420 (4%) to 44 221 (48%), whereas glucagon auto-injectors increased from 0 to 16 425 (18%) and unmixed syringes decreased from 54 403 (96%) to 28 709 (31%). Prefilled syringes and dasiglucagon auto-injectors accounted for less than 3% of glucagon prescriptions each year.

Figure 1. Glucagon Prescriptions in Medicaid by Glucagon Product From 2012 to 2023.

The dashed line represents the first prescriptions filled for newer glucagon products. Until 2019, unmixed syringes made up 100% of all glucagon prescriptions.

Figure 2. Total Amount Reimbursed by Glucagon Product From 2012 to 2023.

The dashed line represents the first prescriptions filled for newer glucagon products. Until 2019, unmixed syringes made up 100% of all glucagon prescriptions and reimbursement. All values are adjusted for inflation using 2023 US dollars.

Discussion

The number of glucagon prescriptions decreased between 2012 and 2018, but increased between 2019 and 2023 as newer products entered the market. Reimbursement for glucagon increased throughout the period from 2012 to 2023. However, less than 100 000 glucagon prescriptions were dispensed in 2023. The appropriate number of glucagon prescriptions is unknown, but the observed number is likely a fraction of the potential need based on the high-risk population. In 2019, more than 850 000 Medicaid beneficiaries with diabetes used insulin,⁵ an estimate that does not include beneficiaries taking oral medications with the risk of severe hypoglycemia. However, the actual rate of hypoglycemia is unknown and may be changing with the use of newer medications and smart insulin pumps.

Although reimbursement costs increased with the introduction of newer products, the increased volume of prescriptions suggests increased competition in the market. Following their introduction, newer glucagon products made up most glucagon prescriptions in Medicaid.

There are several limitations to this study. First, the analysis is limited to Medicaid beneficiaries and may not be generalizable to the general population. Second, the Medicaid State Drug Utilization data do not include diagnosis codes that would help to determine the clinical appropriateness of each glucagon prescription. Future studies are needed to examine the effect of newer glucagon products on health care use for severe hypoglycemia and the out of-pocket costs faced by patients.

Section Editors: Kristin Walter, MD, and Jody W. Zylke, MD, Deputy Editors; Karen Lasser, MD, MPH, Senior Editor.

Supplement.

Data sharing statement