Thinking About EpiPens: Anaphylactic Shock and Sticker Shock

By now, you've probably heard of Mylan's long-term interest in getting the Epi-Pen listed as an A or B Category Preventive Medicine by the United States Preventive Services Task Force. It is a pretty exclusive club, but EpiPen's prevention of anaphlyaxis is the basis of its claim to this elevated status.  As this excellent article in MedPage Today makes clear, most curative prescriptions can also be seen as preventive in this sense — preventing the progress of disease and, even, preventing death. 

Surely it is the first dollar coverage aspect of the categorization, under Section 2713 of the Affordable Care Act and its implementing regulations, that is the tail wagging the dog here. The plea to make EpiPens available to those that need them seems to be based on a different idea of preventive coverage: that this potentially lifesaving drug delivery device ought to be available to all, so it ought to be an A or B category Preventive Pharmaceutical. It is, in short, the plea for a hidden cost shift.  First dollar coverage of an item billed at roughly $600 out of pocket cost for a two-pack doesn't necessarily  change the manufacturer's price, it just changes the cost to EpiPen consumer into  the cost to the public.

Of course all of this is complicated by Mylan's apparent other long-standing interest in keeping EpiPens from being listed on the generic drug list, except for its own $300 branded generic entry,  where reimbursement would be very different. And, Mylan's efforts to keep the EpiPens4Schools program exclusively tied to their branded EpiPen adds an additional dollop of strategy.

All of this has been seeping out for several weeks at just about the same time as a lively discussion about rethinking automatic insurance coverage for preventive health care under the Affordable Care Act. Turns out preventive care is expensive and, so the argument goes, first dollar preventive care coverage comes at the cost of possibly making treatment of illness itself prohibitively expensive. It is a sort of pitting those who would stay well against those who are already sick analysis.

As both debates — one on the proper role of first dollar coverage for preventive services and medications combined with significant co-insurance obligations for illness treatment and the other about whether preventing anaphlylaxis is truly a preventive service– continue, Mylan will have many strategic choices and counter-choices ahead if their plan is to continue to maximize profit.

It seems likely Mylan will lobby to move the EpiPen to A and B Category Preventive Medications status  unless and until first dollar treatment for those drug categories is removed, in which case Mylan will regroup and urge that the EpiPen remain out of the A and B Category of  Preventive Medicines and, instead, focus on keeping the cost shift alive and hidden  through the use of  end consumer targeted coupons, drug assistance programs, and branded EpiPen requirements for EpiPens4Schools programs. 

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