Amid an already devastating flu season, the story of a Texas teacher who, sick with the flu, skipped her prescription for Tamiflu (oseltamivir) because of a $116 copay, and subsequently died of the illness, has struck many as a tragedy that could have been avoided. It’s especially mystifying because of the high price of such an essential drug. How is it that such a life-saving medicine can be out of reach for so many people?
Heather Holland, a second-grade teacher in Fort Worth, Texas, decided not to fill her prescription for Tamiflu when she saw it would be $116. Her husband says they could have afforded the medication, but she refused to pay out of principle. Three days later, she died from flu-related complications.
It’s impossible to say whether Tamiflu would have saved her life – but the story has provoked alarm and outrage across the country.
It is indeed an outrage – and it only gets worse when you start digging into the pricing behind the story. In fact, prices for Tamiflu – and its equally effective generic form, oseltamivir, are all over the place, depending on where you pay and how you pay. People across the U.S. are reporting paying $90, $25, $106, $10, $200, or $9 – and that is with insurance. Without insurance, paying cash prices people are paying as much as $250 for a prescription for Tamiflu, or $135 for the generic version.
“I just paid $220 for my children’s flu medication (Tamiflu) – they are 6 and 4, not taking them isn’t optional, my daughter got Strain A, more serious one. And this is AFTER insurance coverage AND their state supp. insurance wouldn’t pay because it copay exceeded $100.”
— Johanna (@JohannaMarcia01) January 14, 2018
“The copay for my 7 year old to get tamiflu was $370 dollars. I’m fortunate to have the resources. Others don’t.”
— ♀️♀️ (@abirdabeeaplane) February 10, 2018
What is going on? Here are some facts that can help explain the chaos behind the tragedy.
Tamiflu comes in a generic version
Tamiflu is the brand-name for the drug oseltamivir and is manufactured by Roche pharmaceutical company. Roche sells its version of the drug for a premium price – typically for around $175 cash. But most people who are prescribed the drug will actually get a bottle of generic oseltamivir, which is made by several generic manufacturers. This version of the drug is much cheaper, about $135 for a 10 dose prescription. Whether you are paying with cash or your insurance, be sure you are getting this cheaper generic form of Tamiflu – it is exactly the same medicine and works just as well as the brand version.
Tamiflu comes in 2 forms
Oseltamivir is typically prescribed to adults and most people 13 years or older in 75 mg capsules. But the drug also comes in a liquid form: Children under 13 can be prescribed the oral suspension, which is usually much more expensive than the capsule form – up to $350 for the brand version and around $250 for the generic version. The medicine also comes in a 30 mg and 40 mg capsule, which is sometimes prescribed to children instead of the liquid. Even though the dose is smaller for these smaller capsules, the prices are about the same as the 75 mg form.
Insurance often doesn’t give the lowest price
Even though oseltamivir is the medicine most people take when they are diagnosed with the flu, it is not always covered by health insurance plans. Often, it is put on a “low tier” formulary, meaning that the insurer will cover some – but not all – of the cost. Since there are hundreds of health plans and formularies in the U.S., this means that prices are all over the place. Often times people with insurance find that they are being asked to pay the full cash price of the drug (or even more baffling, sometimes even a higher price).
This is especially true when you factor in available discounts on the drug, such as those featured at GoodRx. Using a discount, prices drop to around $50 in many locations, with average discount prices nationwide at around $60. For many people, this is a lot less than what they would pay with insurance. There’s no catch, but to get the price you must 1) have the coupon and 2) tell your pharmacist you are not using your insurance.
GoodRx also has discounted prices for the brand version of Tamiflu – instead of $175, we have a price of around $140.
As to why prices vary so much from location to location? That’s because pharmacies and PBMs (the companies that actually supply the drug from the manufacturer) are constantly shifting prices around based on supply and demand. It can be terribly confusing but suffice to say that by using GoodRx you can be confident you are getting the lowest prices we can find.
Tamiflu is not the vaccine – and not a cure
Once somebody is diagnosed with the flu, there are very few medicines that actually work to fight the virus. Tamiflu is the most used of these – but even Tamiflu isn’t perfect. In fact, the research has been rather spotty in just how effective the drug is in reducing symptoms and speeding up recovery. Research does show, however, that the drug is most effective when it’s taken as early as possible (it also has some preventive properties, which is why it’s often prescribed to siblings when one child gets the flu).
And no, oseltamivir is not the flu vaccine and not a replacement for getting vaccinated. Even though there’s been doubt about how effective this year’s flu vaccine is, experts agree that it is the best available defense against illness, and reduces your chance of getting the flu by about ⅓. That should be reason alone to get vaccinated.
If you’re like everyone I’m seeing in the clinic these days, your cough may be keeping you up at night, and driving you and your coworkers crazy. Do any of the over-the-counter (OTC) or prescription medications really work for a cough? Let’s walk through it.
First, let’s go through the OTC cough suppressants
- Acute cough due to viral upper respiratory tract infection (URI) is the most common form of cough, and a ton of money is spent on prescription and non-prescription cough medications. You may be surprised to hear that studies show OTC cough suppressants like Robitussin aren’t any more effective than a placebo.
- A review of over-the-counter (OTC) medications for acute cough found fairly disappointing results for the effectiveness of Mucinex and antihistamine-decongestants (Dimetapp, Delsym), and concluded that there is no evidence for or against the effectiveness of those preparations for an acute cough.
- Here’s a cool fact. Honey (specifically Buckwheat honey) can suppress a cough better than over the counter meds in children – and possibly adults – by forming a soothing film over irritated mucous membranes.
Still coughing? Moving on to prescriptions…
- Benzonatate capsules are generic for Tessalon and they do work. How does it work? Benzonatate is a prescription non-narcotic cough capsule that acts by numbing the stretch receptors of nerves located in the alveoli (air sacs) of the lungs, the airways, and the pleura (lining of the lung). You can take it every 8 hours. Studies have also shown that Benzonatate in combination with Mucinex 600mg works even better. Benzonatate and Mucinex suppress a cough to a greater degree than one alone.
- What about adding inhalers when I have a cough? If your doctor hears wheezing with your cough, an Albuterol inhaler (Proventil, Proair) may be prescribed. Routine use of inhalers like Proventil and Proair, however, has not been shown to improve a cough or shorten the duration of a cough.
- The big guns – codeine cough suppressants. If your cough is keeping you up at night, these will help. There are many opiate prescription cough syrups like promethazine/codeine that work well. Their daytime use is limited because you can’t afford to feel dopey during the day, and the codeine may make some folks nauseated. Oh, and it’s habit-forming. Codeine cough syrups are an option for short-term use in desperate times.
Hope this helps.
In what appears to be the worst flu epidemic in years, prescriptions for Tamiflu (oseltamivir) are soaring – outpacing last year’s prescriptions by a factor of 10 or even 14 times higher this year in some states, with a nationwide rate that is more than 5 times higher than last year.
According to a GoodRx analysis of a nationally representative sample of US prescriptions, pharmacy fills for Tamiflu, the most popular medication to treat the flu, are increasing, with some notable geographic variations. In Arizona, Indiana, Wisconsin, and Michigan, prescriptions are up over 10-fold from last year, and other parts of the south and midwest are likewise seeing an exceptionally high prescription volume.
Though there is a vaccine available for the flu, Tamiflu is often prescribed if symptoms start to appear, which helps explain the rapid surge in prescriptions this year. If taken within the first 28 hours of getting the flu, Tamiflu can work to block the actions of influenza in your body, and shorten the duration of the virus. You can also take Tamiflu for up to six weeks to prevent you from getting the flu.
Despite the surge of prescriptions, there are some doubts about whether Tamiflu is even effective for treatment or prevention – more on that below.
The national pattern closely resembles data from the Centers for Disease Control and Prevention, which shows these same states are some of the hardest hit by flu so far this year.
According to CDC data, cases of the flu reached high levels in southern states like Texas and Louisiana in the days before Christmas and then spread through the Midwest and the entire United States.
At the present moment, all states except for Maine, Montana, Idaho, Utah, North Dakota, Hawaii, Alaska, and the District of Columbia are seeing high rates of flu activity. Flu activity has been consistently high over the past 9 weeks and doesn’t seem to be letting up anytime soon. Flu season can last anywhere between 16 and 20 weeks, so experts predict there is still more to come.
To see an interactive view of the flu around this country this year, visit The CDC FluView Map here.
On a national basis, prescriptions for Tamiflu are up more than 5 times last year’s rate. This is a stunning illustration of how bad the flu is – and how much worse it may still get.
A shortage in Tamiflu
The high volume of Tamiflu prescriptions at this point in the season has resulted in a shortage of the medication. While the FDA has not yet confirmed this shortage, doctors and pharmacists in both urban and rural areas are reporting difficulty in accessing Tamiflu for their patients.
Those unable to access Tamiflu this year do have other options. Besides Tamiflu, there are two other influenza medications: Relenza and Rapivab. Both are considered just as effective as Tamiflu and may be easier to access this year. For more information on these medications, see our post here.
Over the counter medications can also help ease symptoms. Read here for more details on over the counter flu medications.
Is it effective?
Tamiflu is sometimes treated as a cure for all cases of the flu, but recent studies call this reputation into question. According to a study-of-studies, or meta-analysis, performed by Cochrane Research of 46 studies involving more than 24,000 people, Tamiflu may provide a much smaller benefit than expected. At best, the analysis found that Tamiflu may only help patients recover one day faster, and may not reduce the number of flu-related complications, like pneumonia. Additionally, it may only reduce the risk of getting sick by 55%. At over $50 per prescription for generic oseltamivir, for some, the benefits may not outweigh the cost.
While these findings don’t negate the use of Tamiflu, they may indicate that it is less protective than we had previously thought.
Tamiflu side effects
There has been recent concern about Tamiflu’s side effects, especially in younger children. Recently, a 6-year-old girl reportedly attempted to jump out of her bedroom window during a hallucination while taking Tamiflu. The FDA has warned of similar side effects previously, noting that:
“Children and teenagers with the flu may be at a higher risk for seizures, confusion, or abnormal behavior early during their illness. These serious side effects may happen shortly after beginning Tamiflu of may happen in people when the flu is not treated. These serious side effects are not common but may result in accidental injury to the patient. People who take Tamiflu should be watched for sins of unusual behavior and a healthcare provider should be contacted right away if the patient shows any unusual behavior while taking Tamiflu.”
More common side effects include nausea, vomiting, headache, and pain. Be sure to speak with your doctor if you or a loved one experience any of these side effects for a prolonged period of time.
Why is the flu so bad this year?
This year’s flu is different from past years. The reason? Around 80% of flu cases this year involved H3N2, a strain of the influenza A virus that is more dangerous and results in more complications. H3N2 is generally also harder to prevent with the flu vaccine, and this seems to be true this year. Experts say that this year’s flu vaccine may be only 10% effective.
How can you protect yourself?
- You can still get your flu vaccine. Even though the flu shot may only 10% effective against this year’s flu, you may still want to consider getting it. Even if you get sick, a flu vaccine can also help ease the severity and duration of the virus.
- Visit your doctor immediately. When true flu symptoms hit, go to the doctor. The sooner you visit, the sooner you can get your prescription for an antiviral medication.
- Wash your hands. This may go without saying, but washing your hands is your best weapon against the flu virus.
- Exercising may help. While heavy exercise may predispose you to the flu, a moderate amount may be protective.
Methodology: Data represents a change in prescriptions for Tamiflu (and generic versions of Oseltamivir) from this season (Dec. 1, 2017, through Feb 11, 2018) compared to last season (Dec. 1, 2016, through Feb 11, 2017). Prescription volume based on a statistically significant sample of fills at US pharmacies. Data comes from several sources, including pharmacies and insurers, and provides a representative sample of nationwide US prescription drug volume.
On September 21, 2017, the FDA issued a drug safety communication for the medication, Ocaliva. The communication highlighted the increased risk of serious liver injury due to being incorrectly dosed in some patients with moderate to severe decreases in liver function.
In response to this safety communication, on February 1st, the FDA added a boxed warning to Ocaliva to highlight the dosage issues.
What is Ocaliva indicated for?
Ocaliva is indicated for the treatment of primary biliary cholangitis (PBC), a chronic liver disease resulting from progressive destruction of the bile ducts in the liver. PCB primarily affects women, as approximately 1 in 1,000 women have this condition. Bile in your liver aids in the digestion of fat and fat-soluble vitamins. When the ducts are destroyed, bile builds up and can lead to inflammation and scarring.
What confusion has Ocaliva dosing caused?
Ocaliva continues to be incorrectly dosed daily instead of weekly, which has led to liver decompensation, liver failure, and death. Healthcare professionals should follow the Ocaliva dosing regimen in the drug label.
Contact your prescriber immediately if you develop any of the following symptoms that may be signs of worsening liver problems: stomach swelling, yellow eyes or skin, bloody or black stool, coughing or vomiting up blood, or mental changes.
Does the FDA require Intercept Pharmaceuticals to do anything else at this time?
Yes. As a condition of approval, the FDA requires Intercept Pharmaceuticals to continue studying the medicine in patients with advanced PBC.
These clinical trials are currently ongoing and FDA expects to receive results in 2023.
The numbers are in: U.S. spending on diabetes drugs increased from $10 billion to $22 billion per year between 2002 and 2012, according to a recent study. And most of that cost was due to skyrocketing prices for one diabetes medication: insulin. Take, for example, Lantus, one of the most popular insulins on the market. The price of a 10-milliliter vial has shot up from under $40 in 2001 to around $275 today.
And these costs are hitting more people every year. About 30 million people in the U.S. have diabetes – up from 10 million 20 years ago – with another 89 million experiencing prediabetes. One study estimates that up to one-third of Americans could have diabetes by 2050. With so many people affected by rising insulin costs, it makes sense to wonder why prices are so high.
Human versus analog insulins
Today there are two major categories of insulin. Synthetic “human” insulin was introduced in the early 1980s and appears under brand names like Humulin R and Novolin 70/30. Genetically modified “analog” insulin was developed in the 1990s to provide several benefits over human insulin. Analog insulins take effect more quickly, their effects are more consistent and predictable, and they reduce the frequency of low and high blood sugar. Popular analog insulins are Lantus, Humalog, and Novolog. The prices for both types of insulin have risen over the years, but analog insulin is often much more expensive (compare $25 for Novolin 70/30 versus $323 for Humalog 50/50).
Due to the added convenience and benefits of analog insulin, 96% of insulin prescriptions in the U.S. are now for analogs. However, a growing body of research suggests that synthetic human insulin is just as effective for managing diabetes.
Manufacturing insulin is expensive
Producing insulin is more expensive than producing many other drugs. Insulin is a large complex molecule, and to create it manufacturers use recombinant DNA technology to engineer insulin-producing bacteria. In pharmaceutical terms, insulin’s size and complexity deem it a biologic. Because insulin is a biologic, any “generic” versions (termed biosimilars for biologic drugs) are subject to much more stringent–and expensive–approval processes by the FDA.
Because of the expense of producing insulin, even when biosimilar versions are produced, they only reduce costs for the drug by about 20%, compared to an average of 80% reduction for standard generics. Basalgar, the first insulin biosimilar, was introduced in December 2016 and costs around $235.
Elevating prices: the “big three” insulin makers
Just three pharmaceutical companies–Sanofi, Eli Lilly, and Novo Nordisk–manufacture insulin, and they vigorously defend their formulations against cheaper biosimilar versions. Sanofi recently brought lawsuits against both Merck and Mylan to avoid production of biosimilar versions of Lantus, its blockbuster insulin.
What’s more, a recent class action lawsuit against the three manufacturers claims that each of the companies set artificially high prices for their drugs in order to gain preferred status within the insurance companies’ lists of covered drugs. This system of discounting has a few problems. First, the discounts may not be passed on to consumers and instead can raise premiums, copays, or deductibles. Secondly, even those who are insured may be required to pay a portion of that inflated price out of pocket, not to mention uninsured patients who are on the hook to pay even more.
Incomplete insurance coverage raises costs
There are several ways that incomplete insurance coverage can negatively impact patients who use insulin.
The first is when the insurers and payers adjust their list of covered drugs (the formulary) to favor cheaper drugs for their member populations, with the result of cutting out coverage for some drugs that are popular. This made big news in late 2017, when CVS Caremark dropped coverage of Lantus in favor of the biosimilar Basaglar. Consumers who used Lantus were faced with the choice of switching to another brand or paying full price for their drug of choice.
Another factor that has led to higher costs for consumers is the increased use of high-deductible insurance or coinsurance plans. With a high-deductible plan, patients are forced to pay the full amount for insulin until they reach their deductible limit, which can be thousands of dollars each year.
Finally, people who use insulin and have Medicare Part D prescription coverage often find themselves in the “donut hole,” where they’ve surpassed their initial Part D coverage limit but have not yet reached their out-of-pocket maximum of $5,000. During that time, they must purchase insulin themselves, although at a 65% discount.
How to reduce the expense of insulin
The expense of insulin has led some people to cut down their insulin intake, which can be extremely dangerous. Rather than risking your health, try these strategies to reduce costs.
- If you have insurance, make sure your brand of insulin is on the formulary. For example, while CVS Caremark dropped Lantus, they still cover Basaglar, Levemir, and Treseba.
- Ask your doctor about switching insulins. Human insulin is a fraction of the cost of analog insulin, and biosimilar Basaglar provides a modest cost savings.
- Keep watch for the introduction of Lusduna, a new biosimilar developed by Merck. Approved by the FDA, Lusduna is currently held up due to a lawsuit brought by Sanofi.
- Use coupons available from GoodRx and insulin manufacturers. Information about coupons are available on the GoodRx page for each drug.
- The American Diabetes Association is advocating for lower insulin prices. Go to https://makeinsulinaffordable.org to join the effort and find more resources for lowering costs.