Epinephrine autoinjector costs remain high for some patients with private insurance
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The costs of epinephrine autoinjectors have decreased since generic options arrived in 2016, but these costs remained high for some patients due to their insurance plans, according to a study.
“In a prior paper, we showed that out-of-pocket spending for the branded EpiPen doubled among privately insured patients between 2007 and 2014, a period during which the manufacturer of this drug tripled the list price,” Kao-Ping Chua, MD, PhD, a pediatrician and health policy researcher with the Susan B. Meister Child Health Evaluation and Research Center at the University of Michigan Medical School in Ann Arbor, Michigan, told Healio.
But since then, Chua explained, EpiPen (Pfizer) has faced growing competition from lower-priced, nonbranded products, such as its own authorized generic autoinjector, the authorized generic version of Adrenaclick (Amedra Pharmaceuticals) and a generic autoinjector from Teva.
“In theory, if use shifted away from the branded EpiPen toward the lower-priced nonbranded products, out-of-pocket spending could decrease, particularly for patients who are exposed to drug list prices through deductibles and coinsurance,” Chua said. “The purpose of this study was to assess whether this, in fact, occurred.”
Study design, results
Chua teamed up with Rena M. Conti, PhD, associate professor of markets, public policy and law at the Boston University Questrom School of Business, to examine the 2015 to 2019 IBM MarketScan Commercial Database of employer-sponsored insurance claims.
Their analysis, published in Journal of General Internal Medicine, included 657,813 patients aged 64 years and younger with continuous enrollment and one or more epinephrine autoinjector fills. The 990,629 patient-years of data included children (46.2%), females (54%) and high-deductible health plan (HDHP) enrollees (19.6%).
According to the researchers, HDHPs cover approximately 30% of Americans with private insurance, with minimum deductibles of $1,350 for individuals and $2,700 for families in 2019.
The five most common products included EpiPen, Auvi-Q (Kaleo), authorized generics of EpiPen and Adrenaclick, and the Teva generic autoinjector. Mean fills per year totals reached 1.5 (standard deviation [SD], 0.9) for children and 1.1 (SD, 0.5) for adults.
In 2015, EpiPen and Auvi-Q accounted for 95.3% of fills. In 2017, a year after the authorized generic version of EpiPen was released, 58% of fills used nonbranded products. In 2019, EpiPen and Auvi-Q accounted for 11.2% of fills.
“Patients increasingly shifted toward nonbranded products starting in 2017,” Chua said. “By 2019, 89% of epinephrine auto-injector prescription fills were for nonbranded products.”
Mean annual out-of-pocket costs peaked in 2016 at $115.80 (SD, $235) and fell to $75.80 (SD, $326.40) in 2019, with consistently higher spending among children and HDHP enrollees.
Specifically, the median out-of-pocket spending per two-pack of autoinjectors in 2019 included $736 for Auvi-Q, $63 for EpiPen, and $10 for each nonbranded product.
Also, the annual out-of-pocket spending for autoinjector fills in 2019 ranged between $0 and $20 for 60.9% of patients but exceeded $200 for 7.5% of patients, or one in 13 patients. The latter group included children (63.3%), HDHP enrollees (62.5%) and patients who only used nonbranded products (64.4%).
The researchers attributed the high percentage of children whose costs exceeded $200 to their need for autoinjectors both at home and at school, requiring them to fill prescriptions more often than adults.
The mean annual out-of-pocket spending for those patients who only used nonbranded products totaled $657.40 (SD, $1,016.80), which comprised cost-sharing mechanisms including deductibles (73%), coinsurance (15.2%) and copayments (11.8%), exposing patients to drug list prices.
Strategies for reducing costs
“I would not say that any of these findings are necessarily surprising. However, they are significant from a policy perspective. Specifically, our findings imply that increased availability of lower-priced drugs can decrease out-of-pocket spending,” Chua said.
“But they also imply that this alone will not solve the drug affordability problem, particularly for patients who are exposed to drug list prices via deductibles or coinsurance,” he continued.
Instead of prescribing branded products, Chua recommended, doctors should default to nonbranded autoinjectors. Also, he continued, doctors should ask patients about how their pharmacy benefits are structured, including whether they need to meet a deductible for drugs before insurance coverage begins and whether they need to pay coinsurance once the deductible has been met.
“If patients are in plans that require deductibles and coinsurance in the pharmacy benefit, doctors should be aware that there could be affordability problems even if they prescribe a nonbranded epinephrine autoinjector,” Chua said. “To mitigate these problems, doctors should prescribe the epinephrine autoinjector with the lowest list price when deciding between products.”
For example, Chua noted that the list price of the authorized generic of Adrenaclick is “quite a bit less” than the list price of the authorized generic version of the EpiPen.
Policymakers also can play a role in mitigating autoinjector prices, Chua said.
“Congress could consider implementing a federal cost-sharing cap for nonbranded epinephrine autoinjectors, analogous to the insulin cost-sharing cap that is currently being debated,” he said. “Even a relatively high cap like $50 could make a big difference because most people only fill epinephrine autoinjector prescriptions once per year.”
The researchers plan on continuing their work, too.
“Deductibles and coinsurance are accounting for a growing share of out-of-pocket spending in privately insured patients, in part because plans are increasingly using these cost-sharing mechanisms in their pharmacy benefits,” Chua said.
“If this trend continues, the improvements in out-of-pocket spending observed in this study may attenuate over time,” he continued. “It will therefore be important to continue to monitor trends in out-of-pocket spending using more recent data.”
References:
- Chua, KP, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2017.0252.
- Costs for emergency allergy injectors still high for some? https://www.eurekalert.org/news-releases/958512. Published July 12, 2022. Accessed July 13, 2022.
For more information:
Kao-Ping Chua, MD, PhD, can be reached at chuak@med.umich.edu.
Perspective
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I am not surprised by these findings, as they are consistent with the patient experiences reported to Allergy & Asthma Network. However, it is disappointing that even with the introduction of generic epinephrine autoinjectors, the out-of-pocket costs remain so high due to copay accumulators and HDHPs that do not adequately cover these lifesaving medications.
Although the study covered through 2019, results would be very similar in 2022 because more families have fallen prey to these high-deductible plans and rebate/copay games to shift costs to patients.
Doctors can help their patients understand the current treatment options and explore out-of-pocket costs for each option. Moreover, doctors can share prescription assistance programs and medication programs such as NeedyMeds or GoodRX. Finally, doctors should advocate for pharmacy benefit managers and payer policy reform to protect patients from these practices.
Members of the state and federal government should support policy to reform drug pricing, including pharmacy benefit manager reform. Drug pricing transparency should evaluate where we can reduce costs throughout the drug delivery chain, including manufacturers, wholesalers and pharmacy benefit managers.
Ultimately, all essential lifesaving medications should be available to all patients for $0 out of pocket. However, it will take all stakeholders’ willingness to reconsider the drug delivery chain to achieve this goal in a cost-effective manner.
Perspective
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This study reinforces how cost is significant for some patients regarding prescriptions for auto-injectable epinephrine. Studies show low carriage rates and lack of initial prescription fills as well as refills. The cost issues noted in this study likely play a contributing role, even though this is a potentially lifesaving therapy.
We also have seen tremendous variability in prices based upon patients’ insurance/pharmacy benefit plans. Price gouging can have tremendously deleterious consequences as well, including the fact that some patients may not be able to afford the purchase of an epinephrine autoinjector.
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