ASCP Policy Statement on Mandatory Tablet Splitting for Cost Containment

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Preamble

Some health care payers have recently established policies that deny the availability of the lower strengths of certain medications to their enrollees. They require prescribers and patients to use only the higher strengths. When a patient needs a lower strength of the medication, the patient is required to use a portion of a tablet of the higher strength formulation. Health plans have adopted these policies because some manufacturers have established the same or similar prices for different strengths of tablet dosage forms of the same medication. Health care payers can save money for their programs by denying coverage for the lower strength dosage forms. For example, the 20 mg tablet and the 40 mg tablet of a particular drug may have the same price. By prescribing one-half tablet of the 40 mg strength instead of one full tablet of the 20 mg strength, the cost of the medication can be approximately halved. In selected cases, prescribers and pharmacists have taken advantage of this pricing structure to assist low-income patients with affordability of their medications. However, patients must be able to split tablets and understand how to take the medicine properly. In addition, the patient must agree to this change and be willing to follow through. Almost 50% of adults over the age of 65 have arthritis. Many of these adults lack the manual dexterity needed to cut tablets in half. In addition to arthritis, many older adults have visual impairment, tremors from Parkinson’s disease or other conditions, and other functional impairments that limit their ability to split tablet dosage forms. The purpose of this statement is to highlight this practice of certain health care payers, and to emphasize the negative impact of this practice on older adults who are enrolled in these programs.

Position

The American Society of Consultant Pharmacists strongly opposes policies to deny payment for lower strengths of tablet dosage forms, or otherwise mandate splitting of tablets by patients. Older adults often need lower doses of medication than younger adults and are especially at risk from such policies because they are often unable to split tablets due to:

  • Arthritis or other impairment of manual dexterity
  • Parkinson’s disease or other tremors that affect ability to split tablets
  • Cognitive impairment that limits the ability of the patient to understand or remember instructions for tablet splitting
  • Visual impairment

These limitations may result in patients missing doses of the medication, discontinuing therapy without knowledge of the prescriber, or sometimes receiving excessive doses of medication.

Background

When forced to split higher strength dosage forms, these older adults are likely to skip doses or stop using the medication because of the difficulty of splitting tablets. This nonadherence to therapy may lead to decreased quality of care and quality of life, with an overall increase in health care costs. Older adults with cognitive impairment may have difficulty remembering to cut the tablet in half or difficulty understanding the instructions for tablet cutting. As a result, these patients may take full tablets inadvertently, and experience toxicity from receiving a higher dose of medication than was intended by the prescriber. The stability of medications is generally studied with intact tablets. The effect of exposing cut tablets to the environment, as when tablets are cut in half in advance of when the dosage is due, is often unknown. It is known that many medications decompose rapidly when exposed to air and/or moisture. For these reasons, cutting a supply of tablets in half ahead of when the individual dose is due, by a pharmacist or caregiver, is generally not desirable. Although sometimes done out of necessity for individual patients, a reimbursement policy that forces this practice to occur on a widespread basis could lead to unpredictable and undesirable public health consequences. Finally, when tablets are split, the split fragments are not always the same size. When the tablet does not split evenly, the patient can receive an excessive dose of medication from one fragment and an inadequate dose from another fragment. This variation in the size of the dose from day to day can have a significant health impact with some medications. Approved by the ASCP Board of Directors, July 21, 2000. Developed by the ASCP Policy Council.

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