Background: In recent clinical trials, some SGLT2is and GLP-1 receptor agonists have been shown to reduce cardiovascular events, leading to their prioritization for patients with cardiovascular disease in diabetes care guidelines. However, because these medications are costly, oftentimes medication access is limited by insurance companies.

Objectives: To determine the frequency that physicians encounter cost-related barriers to prescribing new diabetes medications.

Methods: We mailed a survey to a national sample of 720 primary care physicians (PCPs) and 480 endocrinologists in 2016 (adjusted response rate, 41%). Physicians were asked how often their patients were unable to start a new diabetes medication in general, and, specifically, an SGLT2i, because it was too expensive. Physicians also reported the frequency of completing a prior authorization (PA) for a new diabetes medication.

Results: In 2016, 28% (N=101) and 37% (N=129) of physicians reported that their patients were unable to start medications in general, and specifically, SGLT2is, due to costs “most of the time”/“always.” More PCPs (45%, N=86) than endocrinologists (26%, N=43) were unable to start SGLT2is due to costs. Daily PA were reported by 43% of physicians (N=151); 62% (N=101) endocrinologists completed PAs daily. Adjusting for specialty and panel size, physicians with >50% of patients age >65 were more likely to report that patients were unable to start a new medication or SGLT2i due to costs (OR=2.25, 95% CI=1.38-3.67; p=0.001 and OR=1.63, CI=1.02-2.60, p=0.04). Endocrinologists (OR=5.03, CI=3.09-8.18; p<0.001) and physicians with >1000 patients in their panel (OR=2.69, CI=1.61-4.49; p<0.001) were more likely to complete PAs daily.

Conclusions: U.S. physicians experience significant cost-related barriers to prescribing new diabetes medication classes. Pharmacy benefit management strategies will need to be updated to facilitate access to glucose-lowering medications with clear cardiovascular benefit.


S.A. Ham: None. A. Nathan: None. N. Laiteerapong: None. R.M. Sargis: Advisory Panel; Self; CVS/Caremark. M.T. Quinn: None. E. Huang: None.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at