Split your pills More health insurers are endorsing the practice, but some physicians say it’s risky.

Smart shoppers can’t resist a two-for-one sale. But should you purchase prescription drugs the same way you buy pizza or canned corn? For years, people who take daily medications have saved money by asking their doctors to prescribe pills with double the dose they need, which they then cut in half with a knife.

Although skeptics say the practice may be unsafe, a growing number of health insurers are encouraging patients to split pills as a way to combat the rising costs of prescription drugs. In June, UnitedHealthcare, one of the nation’s largest managed-care companies, advised members in Wisconsin to discuss pill splitting with their physicians. The insurer plans to introduce the program nationwide before the end of the year.

“Consumers are asking what they can do to bring their costs down,” said Tim Heady, chief executive of UnitedHealth’s Pharmaceutical Solutions drug benefit business. “This program provides better access to important drugs and can improve compliance with these medicines by helping them to be more affordable and accessible to more people.” U.S. Veterans Administration hospitals and some state Medicaid programs also ask patients who are prescribed certain medications to split pills.

But although the practice can save money for insurers and patients alike, is tablet splitting a good idea? Representatives for the pharmaceutical industry and drugstore owners say no. Other experts insist that, in some cases, medical consumers can divide and prosper.

Splitting pills saves cash because of a strategy employed by the pharmaceutical industry called “flat pricing.” Although a gallon of milk costs considerably more than a half gallon, there is often little or no price difference between high and low dosages of medications. For instance, drugstore.com recently offered 10 tablets of 100-milligram Viagra for $93.99, which is the same price it charged for an equal number of 50-milligram Viagra tablets.

Drug manufacturers use flat pricing to keep consumers from switching to cheaper brands if they need to increase dosage, said Dr. Michael P. Cecil, a Covington, Ga., cardiologist whose book “Drugs for Less” lists about 100 pills that can be safely cut in half as a way to battle the rising costs of prescription drugs.
According to the Henry J. Kaiser Foundation, spending on prescription drugs in the United States rises more than 10% a year. Patients who pay for their own medications can reduce their drug bills by up to 50% with pill splitting. For example, someone who halves a double dose of the top-selling cholesterol-lowering drug, Lipitor, could save close to $600 a year. But even people whose health insurance covers prescriptions may be able to save a few dollars. For instance, UnitedHealthcare members who agree to split pills are only required to pay half the usual out-of-pocket co-payment for their medications; a typical $25 co-payment drops to $12.50.

The savings for healthcare companies can also be substantial. The Veterans Administration, for example, trimmed $46.5 million from its annual drug tab in 2003 simply by asking patients to split Zocor, a cholesterol drug. “We were able to treat two patients for the price of one,” said pharmacist David Parra, of the Veterans Affairs Medical Center in West Palm Beach, Fla.

Drug manufacturers and pharmacies oppose pill splitting, arguing that it’s too difficult to divide a tablet into equal halves, especially for the elderly and people with poor vision or arthritis. The Pharmaceutical Research and Manufacturers of America, an industry organization, and the National Assn. of Chain Drug Stores discourage the practice. “It’s a lot of responsibility to put on the patient and doctor,” said Jeff Trewhitt, a spokesman for the pharmaceutical group. “We strongly urge that pill splitting not be pursued.” Neither Trewhitt nor Mary Ann Wagner, vice president of pharmacy regulatory affairs for the chain drugstores group, could provide estimates of how much money their respective industries would lose if pill splitting became more widespread. But a 2000 study estimated that if all Americans who take just the 12 most commonly prescribed psychotropic drugs — which include antidepressants and antipsychotics — split pills, consumers would save nearly $1.5 billion.

Some doctors oppose tablet splitting too. Emergency room physician Charles Phillips said he has opposed the practice since some of his patients who were Kaiser Permanente members in Fresno began telling him that they were required to chop double doses of certain medications. When he examined their drug bottles, he was alarmed to find pill fragments of all sizes. “They’d go from big, to little, down to dust,” said Phillips, who was a plaintiff in a 2002 lawsuit questioning the legality of managed-care provider Kaiser Permanente’s pill-splitting program, which it began in the early 1990s. (The lawsuit was unsuccessful; Kaiser spokeswoman Beverly Hayon said the insurer’s pill-splitting program has been voluntary since its inception.)

Critics such as Phillips charge that splitting a pill too often produces unequal fragments, leading to erratic dosing. A review last fall in the Medical Letter on Drugs and Therapeutics found that trained pharmacists are at best able to divide tablets into roughly equal halves about two-thirds of the time, even when using pill cutters available in drugstores. In one experiment, just 27% of tablets divided equally. However, properly chosen pills can be split as a way to save money, said Dr. Gianna Zuccotti, deputy editor of the Medical Letter.

Many drugs remain active in the body for a long time, so subtle variations in dosage won’t make much difference, she said. In fact, Parra and colleagues recently published a study in the American Journal of Cardiology showing that patients at six V.A. hospitals who split Zocor had cholesterol levels similar to those of patients who took whole pills. Zuccotti suggests splitting pills one at a time and taking the second half as the next dose (rather than chopping up a month’s worth and tossing the fragments back in the bottle) to be sure you don’t take too much or too little medicine at once. Don’t split pills with a knife or razor, said Parra, because it’s easy to slip and cut yourself. “Definitely use a pill splitter,” he said.

Most pharmacies carry a few kinds; Cecil recommends buying one with a clear cover and a V-shaped tip, which allows more precise placement of the pill. Certain pills should not be split, including capsules; enteric-coated tablets; extended-release pills; and pills that combine two drugs in which one dose increases with tablet size but the other does not. What’s more, some drugs have a “narrow therapeutic index,” meaning that tiny changes in dosage can dramatically change their effects. To be safe, always talk to your doctor or pharmacist.