Hard to swallow

Ubiquitous, lifesaving, expensive: the EpiPen has become the symbol of soaring drug prices. The ready-to-use treatment for allergic emergencies comes in packs of two, whose price has quadrupled since 2004 to over $600. Its maker Mylan announced a cheaper version, but public outrage continued—especially when USA Today reported that former National Association of State Boards of Education president Gayle Manchin, who promoted EpiPen mandates for schools during her presidency, is the mother of Mylan CEO Heather Bresch. Bernie Sanders thundered on Twitter, “While Americans are dying because they can’t afford Mylan’s egregious drug prices, the company’s CEO got a 671% raise to over $18 million.”

Congressional hearings about the price of EpiPens followed, but Mylan is not the only company raising prices aggressively. Canada-based Valeant also buys the rights to drugs and increases their prices—by 212 percent in one case and 525 percent in another, both on the same day it gained the rights to them. Perhaps most infamous: Turing Pharmaceuticals, which raised the price for a single tablet of the anti-parasitic Daraprim from $13.50 to $750 after buying the U.S. rights to sell it. The drug, whose discovery dates to 1952, sells in Australia for 26 cents per dose.

Critics fault the FDA’s byzantine drug-approval system for allowing companies de facto monopolies. Drug patents normally expire after seven years, but companies have mastered ways of extending them: They then encourage doctors to switch patients to closely related drugs (with new patents) as generic competition finally appears for the old ones. Drug shortages contribute too, as when the Lyme disease drug doxycycline became scarce in 2014.

What can patients do? Shop around. Comparison shopping once required a lot of time on hold with pharmacies, but online tools like GoodRx and Blink Health simplify it greatly.

What can patients do? First, shop around, since prices can vary wildly from one pharmacy to another. As one example, the anti--nausea drug ondansetron ranged from $13 to $183 for a 30-day prescription at pharmacies in my area. Comparison shopping once required a lot of time on hold with pharmacies, but online tools like GoodRx and Blink Health simplify it greatly. Consumer Reports also suggests looking outside the traditional pharmacy chains: independent local pharmacies, grocery stores, even Costco (whose pharmacy doesn’t require a membership) all often have lower prices. Surprisingly, simply asking for a better price may also help.

Where an individual drug is expensive everywhere, cheaper options often exist. For example, many prescriptions that combine two active ingredients in one pill cost more than taking the same ingredients separately. One egregious example is Duexis, combining two cheap over-the-counter medicines to make a prescription medicine at a price that can top $800 a month. Manufacturers of such combination drugs argue that taking one pill instead of two justifies the price, but Duexis’ active ingredients sell separately in generic form—over the counter—for $10 a month.

Families of similar medications also often have cheaper and more expensive choices, and where they don’t, a doctor may be able to prescribe a more affordable class of drug for the same condition. One choice many experts don’t recommend: “Canadian” online pharmacies, many of which ship drugs from poorly regulated sources in India and China. Overseas, counterfeit, and improperly made drugs are a major problem.

Vestiges of competition still exist in the drug market: compounding pharmacies now sell Daraprim’s active ingredient for $1 a dose, and CVS recently announced a generic EpiPen equivalent for $110 a pair. The next four years also herald change, even if details remain uncertain. President Trump has stated the drug companies are “getting away with murder”—and in a rare moment for both men, Bernie Sanders’ reply began, “Trump is right.”

—Charles Horton is a Pittsburgh doctor and a graduate of the World Journalism Institute mid-career course