The company seeks the most cost-effective medications, she said, but added that Express Scripts does not establish the price a patient pays for any medication, and its clients – employers, health plans and government agencies – decide how much will be paid by a patient.

In Gainesville, Texas, Jerry Meece, a clinical pharmacist and certified diabetes educator, said he spends far too much time trying to figure out what patients can afford versus what meds are most appropriate for them.

“These patients are desperate. They do without their insulin, skip doses, lower their prescribed dose to stretch out the insulin they have, and end up in the emergency room or ICU with long-term complications such as kidney failure, leg amputations or vision problems,” Meece said.

Even some patients who can afford the higher prices are endangered because the benefit managers are playing musical chairs with the different brands of insulin they authorize, some doctors said.

“I’m being told to make patients switch their insulin for no good reason except to make somebody more money,” said Dr. Loren Wissner Greene of New York University’s Langone Medical Center.

Greene, an NYU clinical professor of medicine, worries that her patients are confused by the flip-flopping.