Several weeks ago I went to fill a prescription for an injectable medication that requires the use of an auto-injector. While it’s not an EpiPen, it’s similar in that the prescription is delivered through a pen-like device. It’s also similar in that the price doesn’t seem to make much sense. With insurance, the medication costs $15. The plastic pen to inject the medication? $180.
While the medication I take greatly improves my quality of life, not filling my prescription isn’t as life-threatening as not getting epinephrine is to a person with severe allergies. So I took the medication cartridges and set out to find a cheaper delivery device.
In the time I spent searching for an auto-injector alternative, the news of EpiPen’s massive price increases broke. Since 2007, EpiPen’s wholesale pricing went from $56.64 to $317.82, a 461 percent increase. As a consumer, the prices you are going to pay are much higher – with some paying upwards of $600 for a two-pack (the only way the drug can be sold).
Update: On Thursday, August 25, Mylan, the pharmaceutical company that makes EpiPens, announced it is offering a copay assistance program that will take $300 off of the price consumers pay for EpiPens. Mylan is also making it easier to qualify for its patient assistance program which provides free EpiPens to under-insured or uninsured families.
“We’re seeing a lot of [people struggling to afford their EpiPens] because of high-deductible [insurance] plans or patients being inadequately insured,” said Sakina Bajowala, M.D, a board-certified physician in pediatrics and allergy and immunology practicing in North Aurora, Illinois. “The root cause of this is that Mylan has made the poor decision to jack up prices by hundreds of percents over the last few years.”
“I think it’s a shame. Patients are struggling with this and doctors are too,” said Jennifer Caudle, D.O., Family Physician and Assistant Professor at Rowan University School of Osteopathic Medicine. “The first thing I thought was ‘Oh my gosh.’ This isn’t Tylenol. This is a life-saving medication. People die every year from anaphylactic shock.”
According to Food Allergy Research and Education (FARE), up to 15 million Americans have food allergies, including one in 13 children under the age of 18. Anaphylaxis is a severe, life-threatening allergic reaction that causes over 300,000 pediatric visits to the emergency room each year. When the signs of anaphylaxis – difficulty breathing, hives, dizziness – occur, timely delivery of epinephrine, the medication in an EpiPen, can be the difference between life and death.
“The times where we need this medicine are usually an emergency. If you are thinking of using it, it’s probably an emergency,” Caudle said. “In a situation that’s potentially life-threatening they are great to use. If someone is not breathing or can’t cope it’s great to have something you can easily use.”
For Those Struggling to Afford an EpiPen
For those who want an EpiPen specifically but can’t afford them at their current prices, coupons do exist. There are coupons marketed as zero co-pay coupons, Bajowala said. “However, in reality for many patients, especially ones with high-deductible plans, their co-pay does not end up being zero,” she added. “It simply takes $100 off the out-of-pocket price of the EpiPen two-pack after insurance pays.” For example, if your bill after insurance is $300, you would now owe $200 for each two-pack you purchase.
“For many of my patients, even after the coupon kicks in they still have an out-of-pocket expense of over $400 for each two-pack that they need,” Bajowala explained. “For children, this is especially problematic because they don’t just need one two-pack. They need one two-pack at home, one two-pack at school, they need another two-pack at daycare, another set at grandma’s or a babysitter’s house – and it adds up if you are spending $400 or $500 a pack.”
Mylan, the pharmaceutical company that makes EpiPens, also offers a program which provides low-cost or free EpiPens to people who don’t have insurance. While this can help uninsured patients, it leaves patients who don’t have the best insurance coverage in the lurch, Bajowala explained: “They don’t qualify for the uninsured program, but they don’t have enough insurance coverage to save their wallet from major damage when they do go to the pharmacy.”
“Families simply cannot afford to spend that much money on a medication [when] the expiration date is only a year and they have to replace it every year,” she said. “It’s a very, very expensive insurance policy when they are already spending a lot of money to have health insurance coverage.”
Alternatives to Using an EpiPen
There are other alternatives to using an EpiPen. “When patients have these issues, I offer them a few options,” Bajowala said. One of those options is Adrenaclick, an auto-injector pen that delivers epinephrine, and has generic alternatives. “The only downside is that it does leave an exposed needle when you are finished with the injection, so you have to be a little more careful when pulling out,” Bajowala said. “But the cost difference for some patients can be substantial, saving them hundreds of dollars on the prescription.”
The other option is to use a syringe and draw the epinephrine out of the vial, said Caudle. “One of the things about using a syringe is that there are many more steps,” Caudle explained. “There are two pieces of equipment. You need to use alcohol to wipe off the vial first. There’s a lot more room for error.”
“Epinephrine is not an expensive drug,” Bajowala told The Mighty. “In fact, it’s a very inexpensive drug.” The New York Times reports that 1 milliliter of epinephrine costs less than a dollar in the developing world, and that less than a third of a that goes into an EpiPen. “The cost is coming into the development on the device and marketing of the device,” Bajowala said. “Most of their expense has been marketing rather than really investing in the device itself, because the device really has not changed much over the last few years.”
Syringes, unlike EpiPens, are not expensive. In many states, you can get 1-milliliter insulin syringes without a prescription. Upon learning this was an option, I went to a local pharmacy in New York City, and bought 10 syringes for $5 without a prescription – thus solving my $180 auto-injector problem.
For those interested in using syringes to deliver epinephrine, there are other factors to consider beyond the price of epinephrine and syringes. Studies have shown it takes patients longer to draw-up the appropriate amount of epinephrine and deliver it, Bajowala said. “Parents took approximately 142 seconds to draw-up the appropriate dose of epinephrine. For physicians it was 52 seconds, for general nurses it was 40 seconds, and for emergency department nurses it was 29 seconds.”
Bajowala also advises against drawing up the medication in a syringe ahead of time. “That’s also been researched and unfortunately epinephrine is very susceptible to the effects of visible light on the stability of the medication,” she said. “For it to maintain its effectiveness, it needs to be protected from light and heat. Therefore, drawing it up in advance could potentially degrade the effectiveness of epinephrine.”
“Talk with your doctor first,” Caudle advises. “There are some patients I wouldn’t recommend this for. What I would say is, ‘You really need to talk to your doctor to see what options they have available. As a doctor, I would need to figure out, is the syringe and vial a reasonable option for this patient given their age and type of allergy?”
If you are thinking of using your expired EpiPen, think again. Both Bajowala and Caudle advise against using expired medication. However, if using an expired EpiPen is the only option you have available, it most likely won’t hurt you – but it may not help you either. “We can’t advise our patients to administer expired epinephrine as a first line because there is no guarantee of the stability of the medication in that device.” If the epinephrine in your EpiPen looks discolored or has precipitation, throw it out, Bajowala advised.
“At the end of the day, we need to not have a monopoly in the marketplace,” Bajowala said. “The FDA is going to need to fast-track approval of alternatives for the EpiPen device so there is competition in the marketplace and the price can be driven down to more affordable levels. Having a monopoly in this area has encouraged greed. We need to have more options available and more safe options available.”