Type 2 Diabetes: medications and paying cash

Overview

Type 2 diabetes is high blood sugar caused by the body responding poorly to its own insulin and, over time, making less of it. Treatment aims to keep blood sugar in a range that prevents damage to the eyes, kidneys, nerves and blood vessels, and increasingly to protect the heart and kidneys directly.

Metformin remains the first medicine for nearly everyone because it is effective, safe and costs very little. Beyond metformin the choice depends on what else the patient has. SGLT2 inhibitors such as empagliflozin are favored when there is heart failure or kidney disease; GLP-1 agonists such as semaglutide and dulaglutide when weight or cardiovascular risk is the concern; DPP-4 inhibitors such as sitagliptin for a gentle add-on; sulfonylureas such as glipizide where cost is the overriding issue; and insulin when the others are not enough.

Most people will take two or three of these over time, and the prescriber will reassess as blood sugar, weight, kidney function and heart risk change.

Choosing between the options when you pay cash

This is the condition where the cash-pay picture is most uneven. Metformin, glipizide and the older insulins cost pharmacies very little, and their cash prices are mostly dispensing fees. The SGLT2 and DPP-4 tablets and the GLP-1 injections are brand products, or are only beginning to see generic competition, so they are priced at a different order of magnitude. A patient paying cash can be on a combination that costs almost nothing or one that costs a great deal, for similar blood sugar control.

Three practical points follow. First, ask the prescriber which parts of the regimen are doing the clinical work; a brand add-on with a modest effect may be the one to question. Second, for the brand drugs, the manufacturers’ assistance programs for uninsured patients are the first thing to check, before any pharmacy comparison. Third, combination tablets that bundle a brand with metformin are convenient but can cost more than the two prescriptions separately; ask for both quotes.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Metformin
  Immediate-release tablet, Extended-release tablet (several non-interchangeable types), Oral solution (Riomet)
  Generic: Yes · Two or three times a day with meals, or once a day extended-release
• Empagliflozin
  Tablet, Combination tablets with metformin (Synjardy), linagliptin (Glyxambi) and both (Trijardy XR)
  Generic: No · Once a day
• Semaglutide
  Prefilled multi-dose injection pen (Ozempic, Wegovy), Single-dose injection pen (Wegovy), Tablet (Rybelsus)
  Generic: No · Once a week
• Dulaglutide
  Single-dose prefilled pen, injected once weekly
  Generic: No · Once a week
• Sitagliptin
  Tablet, Combination tablets with metformin (Janumet, Janumet XR)
  Generic: Yes · Once a day
• Glipizide
  Immediate-release tablet, Extended-release tablet
  Generic: Yes · See the guide
• Insulin Glargine
  Prefilled injection pen, Vial for use with insulin syringes
  Generic: Yes · Once a day
• Tirzepatide
  Single-dose prefilled injection pen (Mounjaro, Zepbound), Single-dose vials (Zepbound, sold through the manufacturer’s self-pay channel)
  Generic: No · Once a week
• Linagliptin
  Tablets, Combination tablets with metformin, empagliflozin, or both
  Generic: No · Once a day
• Glyburide
  Tablets, Micronized tablets, Tablets combined with metformin
  Generic: Yes · Once a day
• Canagliflozin
  Tablets (Invokana), Tablets with metformin (Invokamet), Extended-release tablets with metformin (Invokamet XR)
  Generic: No · Once a day
• Liraglutide
  Prefilled multi-dose injection pen
  Generic: Yes · Once a day
• Glimepiride
  Tablets
  Generic: Yes · Once a day
• Dapagliflozin
  Tablets
  Generic: Yes · Once a day
• Pioglitazone
  Tablets
  Generic: Yes · Once a day
• Insulin Lispro
  Vials, Prefilled pens, Cartridges
  Generic: No · See the guide
• Insulin Aspart
  Vials, Prefilled pens, PenFill cartridges
  Generic: Yes · See the guide
• Insulin Degludec
  Vial, FlexTouch pen, U-100, FlexTouch pen, U-200
  Generic: No · Once a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Which of my medicines is doing most of the work, and could any be replaced by a cheaper class?
• Is there a reason I need the combination tablet rather than the two components?
• Do I qualify for the manufacturer assistance program for my brand medicine?
• How often should my kidney function and A1c be checked on this regimen?
• What should I do about low blood sugar if I take glipizide or insulin?

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