Pill-splitting   (July 4, 2009)

Many years ago, I had read about the idea of pill-splitting to save money. For many medications that come as tablets or pills, it's possible to split them in half (either with a knife or a specialized pill-splitting device) and take a half-dose at a time. The cost saving is based on several assumptions:

* that the pill can readily be split in half. For pills that come as scored tablets, it's easy; for others, it may or may not be easy to split them into two equal halves without them crumbling into a mess.
* that the dose you are taking is half of a bigger dose that the company makes. For instance, if a patient is on a medication which comes in 25 mg and 50 mg tablets, and is doing well on the 25 mg strength, then the patient could purchase the 50 mg strength and cut the 50's in half and get the correct strength.
* that your physician will write a prescription for double the strength of what you actually need.

Why bother? It's because of the way pills are priced: frequently, medications which are available in "double" strengths are comparably priced to their lower-strength sibling, being only slightly higher per pill. So, if the medication that I describe above costs $.95 per pill for the 25 mg size, then 100 pills would cost $95.00 and would last 100 days. But if the 50mg size costs $1.00 per pill, and the pills are split, then 100 days' supply would require only 50 pills, and cost the patient only $50.00!

Medco's website lists several criteria that should be considered by you and your physician when thinking about splitting pills. Unfortunately, the list cannot be accessed through Google. Here's a  modified version of their criteria:

* The pill should be taken just once or twice a day.
* When splitting scored tablets, splitting them by hand may lead to less crumbling and more precise halves than using a "pill splitter" device.
* Consider using a "pill splitter" device to split NON-scored tablets.
* Only cut one pill at a time to make sure the medication is dosed properly and remains stable. This helps you get a single whole pill in a 24-hour time period if you're on a twice-daily dose. For a medication taken one time per day, take ½ tablet on the first day and the other half of that tablet the next day. For a medication taken twice a day, take ½ tablet in the morning and the other half of the tablet that afternoon or evening).
* Do not split medications that are not designed to be cut, such as capsules, and most long-acting tablet dosage forms (medications with names that include two-letter abbreviations, such as "ER", "SR", "SA", "XR", "XL", "CR", or "LA"), delayed release ("DR") or enteric-coated tablets ("EC") tablets that are designed to protect the stomach and/or dissolve after passing through the stomach). Ask your prescriber or pharmacist whether your medication is long acting, delayed release or enteric coated; this cannot be identified just by looking at the tablet.
* Do not split medications with a "narrow therapeutic index" (those medications where even very minor differences between doses can be important). Your prescriber can inform you if your medication has this as a concern.

One discussion I found on line (Which medications can be split without compromising efficacy and safety?) points out that "recommending tablet-splitting to insured patients solely to spare them copay - instructing a patient to take a half tablet to make a 30-day paid prescription cover 60 days - may be considered insurance fraud. However, this is not an issue for patients without prescription coverage."

At least one big insurance company, United Healthcare, actually encourages the practice, and has set up a website about splitting tablets and gives away a tablet splitter: http://www.halftablet.com. Although nominally for UHC patients, this website has helpful information for everyone, including a listing of medications that UHC has found to be splittable, and a list of references supporting the concept of splitting (see the FAQ page).

And another article (from a law firm!) points out some of the concerns about pill-splitting, in an article called Cutting Corners. This article indicates that one HMO (Kaiser) has routinely encouraged pill-splitting.

Should you start splitting pills? If you are on a tablet that can be safely split in half, and are comfortable with the idea, and want to save money, talk to your physician. Ask if he/she will write a prescription for a double-sized strength of your medication so you can start splitting your pills.