Mylan has faced competition before, including from the Auvi-Q before it was recalled from the market. But EpiPen has been able to dominate the epinephrine auto-injector space because of its familiarity to patients and doctors, as well as various issues with its competitors.
Now, EpiPen will go head-to-head with Auvi-Q and with the authorized generic of another auto-injector called Adrenaclick. Last week, CVS Health said it would offer a two-pack of the generic version of Adrenaclick for $110.
Mylan is readying itself for competition; it launched an authorized generic of EpiPen late last year, at half the list price -- $300 for a two-pack.
The list prices for these three products are all over the map: the Auvi-Q, which comes with a voice that talks patients through how to administer the injection, has a cash price for patients without insurance at a slight premium to Mylan's generic EpiPen, which is further undercut by the CVS price for Adrenaclick's generic. But the list price of the product -- a price that the company has made it clear no patient will ever actually pay -- is $4,500.
The list price doesn't reflect what insurers pay because they negotiate secret rebates and discounts. It also doesn't reflect what patients generally pay, because insurance often passes through only part of the cost, through a co-pay or co-insurance. The growth in high-deductible plans, in which patients are on the hook for the full cost of a drug until they hit a dollar limit, is thought to have helped spur public outrage about EpiPen because consumers were increasingly exposed to the escalating list price.
The three companies are offering various kinds of coupons and patient affordability programs to defray the cost to consumers even further. Those programs reveal the varied patchwork that makes drugs affordable.
For example, the Auvi-Q will be free to patients with commercial insurance -- even if they have a high deductible plan, according to Kaléo. In addition to offering a $110 cash price at CVS for the Adrenaclick generic, the company Impax Laboratories is offering a $100 coupon. Mylan is offering a $25 coupon off out of pocket costs for its authorized generic. Coupons cannot be used by people with government insurance.
In a broader sense, these options will give insurers more leverage when trying to negotiate the price of the medication. Insurers and the companies they hire to negotiate on their behalf -- pharmacy benefit managers -- use competition and the threat of excluding a product altogether to wring deeper discounts.
The insurer Cigna announced this month that it would cover only the generic versions of EpiPen and Adrenaclick.
What remains to be seen, however, is whether savings insurers get from the increased negotiating clout are passed on to customers through reduced copays or, ultimately, lower premiums. What the EpiPen maelstrom laid bare, in part, was the complexity of drug pricing and the fact that many middlemen industries can also benefit from high drug prices.
Correction: A previous version of the story misstated the list price of Auvi-Q. The actual list price of the drug is $4,500; the cash price patients without insurance would pay is $360.