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Stephanie Howson/MEDILL

Some pills are "scored," meaning they are manufactured with a line down the middle. Scored pills and tablets are the easiest to split.


What’s best for your wallet may not be best for your health

by Stephanie Howson
Feb 19, 2013



Stephanie Howson/MEDILL

Jack Fincham, professor of pharmacy practice, talks about the risks of splitting pills


Some commonly split pills

Source: consumerreports.org

• Cholesterol-lowering medication such as Crestor and Lipitor

• Antidepressants such as Paxil and Zoloft

• High blood-pressure medication such as Univasc and Zestril

• Medication for erectile dysfunction such as Cialis and Viagra
When Bridgit Sliwak, 32, first moved to Nashville in 2011 each trip to her doctor at Vanderbilt University’s Department of Psychology cost her $100. She was clinically depressed and uninsured.

To increase the time between the expensive appointments, her doctor prescribed 100 milligrams of Sertraline, a generic version of the anti-depressant Zoloft, instead of the 50-milligram dose she was supposed to take and told her to cut it in half.

“I did appreciate it at the time,” Sliwak said. “Not having to go back and see him for a new prescription was better for me.”

Doctors have been advising patients to split medication for more than a decade, but the practice has received added attention in recent years as more people are splitting their prescription pills to save money.

Pill splitting, also called tablet splitting, is one straightforward way for patients to battle the rising cost of prescription drugs in a time of recession. And the benefits of the practice extend beyond consumers: Health insurance carriers and employers also save when plan members decide to split their medication, health industry experts say.

“It’s one of the most common practices right now because of the high charges of co-payments,” said Hossam Maksoud, pharmacist and owner of Community Care Rx, a long-term care and special client pharmacy producer and consulting service located in Flushing, N.Y. “It’s as simple as buying a $5 pill splitter and here you have double quantities for the same payment.”

Though pill splitting may seem simple, studies show that not all drugs can be safely split and many experts warn that the benefits of pill splitting don’t outweigh the potential dangers of the practice.

Jack Fincham, professor of pharmacy practice and administration at University of Missouri, Kansas City’s School of Pharmacy, points out that patient safety is an issue with the practice.

“I really have come major concerns about it,” Fincham said. “It’s really important for patients to understand what type of tablet or capsule that they have… For patients who are really the most important people in all this, it can be very confusing.”

Some pills such as extended release tablets or those with special coatings should not be cut in half. If a pill with a moisture-protective coating is split, the effectiveness of the medication could be compromised.

“It’s not the patient’s fault but moisture and air can impact how the drug is going to work,” Fincham says.

Drugs for certain life-threatening conditions where exact dosages matter greatly, such as blood thinners, shouldn’t be split. Studies have shown that there is no guarantee the active ingredient is spread equally between the two halves of a pill or tablet, which could mean dosage changes that fluctuate each day. Even if a tablet is “scored,” meaning it’s made with a line down the middle to make it easier to split, the dosage in each half can vary.

Another concern is that not everyone is capable of splitting pills effectively such as the elderly or those with arthritis or vision issues. There is also the danger that a patient could forget to split the medication and take a larger dose than prescribed.

Pill splitting as a money saving strategy exists because of flat pricing, a way of valuing prescriptions based on the research and development of a medication rather than the amount of active ingredients in each pill. Flat pricing equalizes the cost per pill of different dosages of the same medication..

Flat pricing protects customers from price fluctuations and gives doctors the freedom to make dosage choices for their patients that are not based on cost. With flat-priced drugs patients can buy a higher dose than they need, split it half and save 50 percent.

For example, 30 tablets of the cholesterol-lowering drug Lipitor cost about $6.67 per pill at Target pharmacies in Chicago whether its a 20-, 40- or 80-milligram dose, according to goodrx.com, a website that displays prices for prescription drugs at a variety of drug stores. A patient who needs a 40-milligram dose of Lipitor could split an 80-milligram pill in half and get 60 doses for $3.34 each.

Even for drugs with varying prices per dose, splitting pills can still provide cost savings.

A 10-milligram tablet of Lipitor is slightly cheaper at around $4.77 per pill. A patient requiring a 10-milligram dose could split the 20-milligram pill, which costs $6.67. That drops the cost to $3.34 per half, a 30 percent decrease.

Beyond offering significant cost savings, pill splitting allows doctors and patients to create dosages that aren’t available on the market for certain drugs.

Dr. Neil Kirschen, chief of pain management at South Nassau Communities Hospital in Oceanside, N.Y., and medical director of the Pain Management Center of Long Island, said it’s not uncommon for patients to split pills because they experience unwanted side effects at higher doses. For patients who are older or chemically sensitive, the lowest dosage available for certain pills can be too strong, which can result in nausea, drowsiness or confusion.

Splitting can also make certain pills easier to swallow and allow a more flexible dosing schedule for patients who want to take portions of their prescribed dose throughout the day.

Despite the risks, pill splitting’s potential to lower bills has not gone unnoticed by health insurance carriers. Many carriers including the Department of Veterans Affairs and the University of Michigan have voluntary pill splitting programs, which offer savings for members, their employers and the insurance carriers themselves.

UnitedHealthcare Services Inc. has arguably the best-known pill splitting program in the country. The Half Tablet Program offers a list of accepted medications available to split, which is composed of hypertension, high cholesterol, depression and diabetes medications, according to a program brochure.

If a member is taking a drug on this list and decides to participate in the program, his or her doctor will write a new prescription for twice the strength and half the quantity of the drug, noting the member’s intent to split the tablets on the prescription. The new prescription is then filled and the member splits each tablet and takes half.

The program gives commercial members the opportunity to reduce copayments and out-of-pocket costs by half, according to Susan Maddux, chief pharmacy officer at UnitedHealthcare.

The Half Tablet Program also helps employers save up to 50 percent on the cost of select medications when their employees participate in the program, according to a program brochure.

Maddux declined to say how much UnitedHealthcare saves through Half Tablet.

She emphasized that the plan is voluntary and only features certain pre-approved medications that have been reviewed by a committee of physicians and pharmacists. Maddux also stressed that pill splitting is a choice to be made between the member and his or her doctor.

There are many ways to split a pill: small guillotines available online and at drug stores, knives, fingers and even one’s teeth. UnitedHealthcare offers its customers pill splitters as experts agree this is the safest way to split a pill because it’s the most exact.

Although pill splitting has its risks, many medications are manufactured with splitting in mind. If a tablet is deemed acceptable to split, this information will be listed on the medication’s label. Many pills are also scored down the middle to make them easier to split. Although the U.S. Food and Drug Administration generally discourages the practice, it drafted guidance in 2011 to regulate tablet scoring.

Many pharmacists recommend compounding as an alternative to splitting. In compounding a drug is custom mixed and often liquefied so patients can take any dosage required. But both pharmacists and health insurance carriers mention the high cost of compounding as a deterrent.

“The problem with compounding is that some plans don’t cover compound pharmacies and patients have to pay out of pocket,” Kirschen said.

According to Maddux, compounding is ranked tier three in UnitedHealthcare’s coverage, which means it is the highest, and most expensive, level of care.

From a safety standpoint compounding pharmacies are subject to lighter regulation than pharmaceutical companies, which increases the possibility of careless oversight and drug contamination. A compounding pharmacy was responsible for the outbreak of fungal meningitis that killed more than 30 people last year.

Compounding medication also takes time. With pill splitting, “I can use a local pharmacy and deliver to the patient the same day,” Kirschen said.

Ultimately experts agree that the decision to split pills should be made by the patient and his or her doctor. Maksoud encourages people who are going to split pills to ask for help. “We usually tell people not to do it themselves, but let the pharmacist do it for you,” he said.

If people are splitting for cost, Jennifer Cerulli, associate professor of pharmacy practice at Albany College of Pharmacy and Health Sciences, asks if there is something she can do as pharmacist to lower the cost such as have the patient try another cheaper drug in the same class. With splitting “the risks outweigh the benefits,” she said.

The proliferation of lower-cost generic drugs on the market is a saving grace for patients battered by the high cost of medication. Patients who split brand-name pills for financial reasons may not continue to split with a generic medication, according to Cerulli. As easy as pill splitting seems, it is still an inconvenience.

Although Sliwak is still uninsured, she no longer splits her medication because she upped her dosage and began to see a less expensive doctor. Currently her Sertraline costs her $5 a month. This is a far cry from the brand name Zoloft, which can cost more than $150 a month.

Could Sliwak pay that much for her pills? “No,” she said resolutely. “I don’t know what I’d do. I really don’t know what I’d do, honestly.”