15 Myths About “Walmart Insulin”

When we talk about insulin prices and how a vial of analog insulin is priced at $275 a vial, often people will suggest just buying insulin at Walmart. Walmart offers Relion brand insulin for $25 a vial “behind the counter” where one can buy this without a prescription.

Is this too good to be true? Yes.

This insulin is older, human insulin. For a short-acting insulin, there is Regular (R) and for a longer-acting insulin, there is NPH. These insulins, utilizing rDNA technology specifically, have been available since 1982. The science behind these insulins has been around for much longer.

The insulin pricing crisis in the United States is mainly centered around the price of analog insulins. Analog insulins are “modern” insulins that are prescription-only. The list price for a vial of a rapid-acting analog insulin is $275. This is over ten times greater than the older, human insulin found at Walmart.

In short, Walmart insulin is different insulin than the insulin we are used to using today. It has not been the “standard of care” insulin for decades, many people with diabetes have never used this insulin and many healthcare professionals have never learned to dose it.

Accessing this older insulin isn’t without financial or logistical burdens. It is not patently affordable or accessible. Additionally, using this insulin, compared with more modern, analog insulins, adds more “biological” and “social” burdens to surviving. The availability of older insulin at Walmart does not solve the overarching systemic problems that actively disincentives the creation of a real insulin safety net for people with diabetes in the U.S.

When people ask “but, what about Walmart insulin?” (“Walmart whataboutism”) and imply we do not have an insulin access problem in the United States because this “Walmart insulin” is available, here are the myths they believe.

#1: People with diabetes know this insulin exists

In their late 2015 article, NPR stated buying some forms of insulin without a prescription was a “little known fact.”. Since then, with more public outrage on high insulin prices, it’s possible that more people know of it’s existence. But, with modern insulin being prescription only and when “many doctors don’t know its possible” , knowing that one can buy insulin without a prescription would be more likely known to patients who are active within diabetes communities. The system, as it is incentivized, has little reason to corral people into purchasing behind the counter insulin and therefore the knowledge of its existence is not universal.

#2: People with diabetes will pave their own way with a more difficult insulin regimen. 

As patients face higher costs for health care, they are often times more and more isolated from providers and preventative care. When they do receive care and don’t feel shame in expressing financial difficulties in affording their prescription drugs, doctors can be dismissive of their concerns or suggest stop gaps such as copay cards and samples. Absent of all other factors, this is not a conducive environment for patient suggestion of a more cost-effective but difficult insulin switch. When people with diabetes switch to over the counter insulin, it is often a decision isolated from their health care providers. If one can’t afford analog insulin, can they afford a health care provider in the first place? Without provider guidance, unless many of us can remember detailed insulin regimens from the 1980s and 1990s (some of us not even alive or diabetic during), one must use their own body as a live experiment to test what works. It’s putting our literal lives on the line. It’s risking trauma. It’s a bold decision, generally advised against, that carries a lot of risk. Enough risk where many who are overburdened by the prices of analog insulin will do whatever it takes to continue using them because it’s what they know and its the regimen their health care providers have trained them on.

#3: A person with diabetes can figure out how much insulin to take. 

In the event a person with diabetes has convinced their doctor to advise them on an over the counter insulin regimen or they are willing to pave their own way and use their own bodies as a live experiment, there are limited resources that exist to help the switch.

Often times, we’re left with forums and blog posts by people who are not healthcare providers. What’s interesting is Certified Diabetes Educators (CDEs) recommend blog posts to people looking to make the switch.

Healthcare providers may be able to advise a person on using this insulin, if one does still have access to a provider. But, this insulin was last commonly used almost 20 years ago. How many healthcare providers were providers back in these days and know how to get a patient on this regimen?

#4: People have access to a Walmart 

The dependency on Walmart is not sufficient enough access. Walmart is not located everywhere and there’s no guarantee that they are accessible by public transportation in their current locations. There are small towns that Walmart has left behind after decimating their local economies. Operating pharmacies in rural and remote areas is difficult. There are many reasons why people are reliant on mail order pharmacies or don’t have the option to shop around for a specific pharmacy. This presents one of the biggest logistical access issues for accessing Walmart insulin.

#5: People can buy insulin without a prescription in all states. 

This is actually no longer a myth but was one for years. The state of Indiana used to require prescription for all insulin, led by the efforts of Dr. Kevin Burke, a former health officer for Clark County, Indiana. In 2020, a bill was passed in Indiana to allow sales of human insulin without a prescription. It is in effect as of January 1, 2021.

#6: $25/ a vial is affordable. 

$25 a vial for insulin is relatively affordable compared to the price of analog insulin but that doesn’t mean it is patently affordable. How many vials does a person with diabetes need? That can be a wide range depending on an individual’s resistance to insulin. Insulin itself isn’t the only component of an insulin regimen either. Syringes are needed to get the insulin into a body. They are pricey and can run $35 for a set of 100. They’re supposed to be single-use only. At a few shots a day, this also adds up quickly. Finally, in order to dose insulin without playing a game of Russian Roulette, test strips are necessary to monitor blood sugars and give a road map for survival. For those lucky enough to have insurance but on over the counter insulin, often times insurers will cover fewer test strips if they don’t have an insulin prescription on record. This is because they assume people are Type 2 people with diabetes who are not insulin dependent. Test strips too are expensive and multiple test strips are needed each day, especially with older insulin.

We acknowledge as that many of these affordability problems would still exist with a federal price cap on analog insulin. That is why we are committed to other goals, including support for Medicare for All.

#7: A person with diabetes can continue to live their normal life without interruptions on this insulin. 

The following write-ups explain the challenge of using this insulin in day to day life. One, by Julia Boss concisely explains the social detriments of using older insulins and how it just does not work in our modern day society, especially in the contexts of employment and school. She also makes it very clear that the social value added by newer insulins does not justify the steep price increases. Another by Nikki Nichols dives into the challenges of timing meals with insulin, especially in children. When using these older insulins, all facets of life must be planned around the insulin and any adverse events, adding social burden to people with diabetes and all whom interact with them.

#8: In emergency situations, this insulin will save a life. 

The diabetes community has seen several members pass away from diabetes ketoacidosis (DKA) because of immediate, short-term insulin rationing. Symptoms of DKA include “excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath and confusion.” It can onset quickly after vomiting and often times, even for someone who has been diagnosed with diabetes, be confused for the flu or other sickness. With those symptoms and under that quick onset time frame, would a person who is afraid of emergency room bills, be able to get themselves a bottle of this insulin and figure out how to dose it in time?

#9: While dosing may be difficult, the insulin itself be consistent and have consistent effects. 

Given other dosing challenges, it’s not even a guarantee that vials of this insulin, or any insulin, will be consistent. A small (not definitive) study found varying amounts of insulin concentration with vials of R and NPH purchased at pharmacies. Varying amounts of concentration would make dosing Walmart insulin much more difficult.

#10: It is safe to dose. 

The FDA maintains that this insulin is safe to dose and many generations of people with diabetes have lived on this insulin. But, there are inherent, biological risks with dosing Walmart insulin because of the timing with when the insulin is active in the body. These risks can be mitigated with careful planning, support and diligence. But, given all the other barriers to insulin access that may push a person towards using Walmart insulin, careful planning, support and diligence may be harder to come by. For example, having adequate testing supplies and access to a medical professional would help but many on this insulin may not be able to afford these. Cognitive function when going through stressful, difficult times or an emergency situation may require more mental and emotional capacity than one has to carefully plan and be diligent. Unpredictable modern work schedules and modern school schedules, without the ability of flexibility, could make it hard to adhere to another rigid biological schedule. When looking at the complete picture, dosing this insulin is more complicated than many choose to believe.

In 2019, Josh Wilkerson passed away after turning to Walmart insulin after aging out of his stepfather’s insurance plan. He was 27.

Four decades before Josh Wilkerson passed away, in the 1980s, side effects and finding people with diabetes dead in bed after using human insulin led some patients to pursue legal action.

#11: Universally, people with diabetes, can take this insulin. 

Allergies to a specific brand of insulin are not unheard of because each producer has different production processes and ultimately the insulin that is produced are different substances. While, for many people, insulins within the same subtype (rapid-acting, long-acting) can be switched out without noticeable differences, others face problems. If someone is allergic to the Novo Nordisk insulin suite, this insulin would be out of their reach.

#12: These exclusive deals will last forever. 

People with diabetes do not have the power or a government mandated guarantee to insulin access. Ultimately, the power with providing this insulin over the counter lies with the insulin manufacturers and distributors. At any given time, the insulin manufacturers could decide to rise the price of these older insulins when selling to Walmart, especially if more people were switching to them.

Back in 2015, it was unclear to some how these economics worked with Walmart. Dr. Jeremy Greene, now of John Hopkins, wondered if it was Walmart’s purchasing power to negotiate a price or Walmart’s ability to take a loss on drugs that allows for this arrangement to exist. Insulin is priced to what the market can bear. Walmart could also decide to back out of selling these or raise prices themselves to consumers. The FDA could step in and decide insulin should not be available over the counter at all. As Dr. Greene stated, the availability of this insulin “as it exists as a marketing effort by a single corporation, it is a thin and fragile thread for those whose lives depend on diabetes.”

#13: It’s fair that pharma should be able to reap higher prices for innovation. 

Analog insulin has been available since 1996. We are past being able to call 20-year-plus old insulin “innovative” and insulin manufacturers have recovered their research and development costs by now. Analog insulin is not even that much newer than Walmart insulin.

Additionally, why is the burden of innovation, generally deemed to support our entire society and not necessarily even diabetes-related, on the shoulders of chronically ill people with diabetes? This is not our burden alone but because we are tied to the system for the rest of our lives, with no other choice but to pay or die, we are exploited as cash cows.

#14: It’s fair that pharma should be able to cover their production costs. 

Through their lawsuits, the Type 1 Diabetes Defense Foundation reversed engineered the production costs of analog insulins. The costs would be just as covered if they were priced similarly to the human insulin available at Walmart.

The production cost of biosynthesized insulins (human and analog) should logically have decreased as manufacturers simplified and optimized production processes since the 1970s. The current production cost for insulin crystals has been reported as low as $42.20 per gram. According to this figure, the estimated production cost for the 35 mg of insulin crystals contained in a standard 10 ml vial at a concentration of 100 IU would not exceed $1.47. Such a production cost would be consistent with 1996 list prices for synthetic analog insulins, $24 per 10 ml vial. It does not explain why list prices per 10 ml vial of the same synthetic analog insulins would increase to current levels (around $255 as of July 2016).

Additionally, a study published in BMJ Global Health estimated the cost of to produce a vial of human insulin is between $2.28 and $3.42, and analog insulin between $3.69 and $6.16.

#15: This will result in cost savings. 

“Costs” in this sense are irrelevant. The “cost” of a vial of analog insulin is the price. There’s no reason why analog insulins have to be priced this high. Because the “cost” to society is merely the price, it’s completely arbitrary right now. If there is no reason to price analog insulin higher than human insulin other than corporate greed, why not let people with diabetes have the agency to choose which kinds of insulin they’d like to use?