It’s September 2016, and Heather Bresch, then-CEO of US pharmaceutical giant Mylan, is called before Congress to answer one big question: why has the price of an EpiPen, a piece of life-saving medical equipment produced by Mylan, risen by almost 500% over seven years?

An EpiPen is an adrenaline auto-injector, used to treat patients who are having life-threatening allergic reactions. Although other brands are available, EpiPen is the most reputed brand on the market. 

In the case of medical emergencies, patients and doctors tend to like certainty – the EpiPen provides this. Dr Ashwani Garg, a family doctor in Chicago, explained that the cheaper alternatives are “okay, but schools aren’t trained on the technology”. She added that “Mylan’s product is used by most and is standard.”

Yet, with a price in 2016 of more than $600 for a two-pen pack, this treatment is unaffordable for people with high deductibles on their insurance plan, or those without no insurance at all in countries such as the US, which lacks universal healthcare. For context, the dose of the active drug (epinephrine) within an EpiPen costs around $1. As of 2024, the EpiPen price remains high. 

The EpiPen scandal for which Bresch was called before Congress in 2016 is just one example of price-gouging in the pharmaceutical industry, a process where prices are increased beyond the level of justification in order to raise profits. 

This is highly regressive, widening inequalities across the world. In other words, it makes the rich richer, and the poor poorer – both in terms of money and access to healthcare. As explained in Theresa MacPhail’s book Allergic, patients in countries such as India have resorted to carrying vials of epinephrine with them, hoping to find a doctor with a syringe if an allergic reaction occurs. This method is undoubtedly cheaper, but extremely risky in terms of dosage. 

To fund this measure, its list price has risen by almost 500%. Bresch also noted that over 50% of the $600 price tag went to companies other than themselves – middle men in the supply chain. 

However, critics say that Mylan is deliberately price-gouging due to a lack of competition. Economically, competition forces providers to work more efficiently, to provide their product at a lower price than others. However, the EpiPen design faced very little competition due to patented technology, meaning that Mylan was essentially free to change its prices as it wished. 

To further its lack of competition, Mylan actively engaged in anti-competitive practices. By allegedly colluding with Pfizer, manufacturer of its main competitor, Adrenaclick, Mylan was able to eliminate its rival from the market, powering its monopolistic hold over the market even more. It’s also argued that Mylan paid other companies to delay releasing their EpiPen alternatives. 

On top of this, Mylan engaged in what they titled ‘Project X2’ – the elimination of single EpiPens from the market, with only two-packs being sold. In emails revealed to the court, Mylan was shown to be scrambling for a “medical rationale” for this choice, and failing to come up with one. 

Despite Mylan’s elimination of its major rival, other products remain on the market. In fact, Mylan launched its own generic epinephrine injector product at half the price ($300 for a two-pack) of the EpiPen in December 2016; a carefully timed move during its legal battle. 

However, health is of the utmost priority and many users feared the generic brand would not be as effective. When they know the EpiPen is tried-and-trusted compared to a newer, unfamiliar alternative, they find a way to swallow the exorbitant price. It’s clear Mylan knew this – why else keep both products on the market? 

In a 2017 interview with CBS, Mylan’s CEO Bresch showed sympathy for sufferers, acknowledging the EpiPen scandal to be the “catalyst to show the system is broken” and encouraging a “coalition” between pharmaceutical companies to improve their pricing strategies. 

These words seem calculated at best, knowing how Bresch benefited from the price rises. During the same seven years in which EpiPens saw their dramatic price-hike, Bresch’s own salary saw a 671% increase, from approximately $2.5m to $19m. 

The class-action lawsuit against Mylan regarding these claims (filed in 2017) continued until 2022, when a $264m settlement was agreed. 

With the EpiPen being a household item for many families, Mylan has perhaps attracted more ire than its counterparts. But its story stood as a warning to other companies. Mylan is not alone in these tactics, with the UK’s Competition and Markets Authority fining giants such as Pfizer huge sums to penalise them for overcharging the NHS in 2023. 

This pricing mechanism is a common strategy. The bigger aim is to evade capture.