Pharmaceutical companies are brilliant. They make profit off of chemicals that can be potentially life-saving. The list is quite impressive: antibiotics for somebody who would otherwise succumb to sepsis, insulin for someone whose pancreas loses the ability to function, antivirals for chronic viral suppression, antineoplastic agents for somebody whose cells have lost their regulatory mechanisms, just to name a few.

The recipe seems to be quite simple: Charge as much money as insurance companies are willing to pay. And do this as quietly as possible: Don’t let the American public know how much a drug costs.

And it seems business is good. Just look at Mylan Pharmaceuticals. Apparently, their CEO made around 19 million dollars last year. Their scheme is nearly flawless. Charge as much as possible for one of the most life-saving medications on the planet: EpiPens.

But Mylan Pharmaceuticals made two crucial mistakes. The first was to increase the price of a medication that most insurance plans don’t cover, thus taking away the secrecy associated with drug prices. And the second, most crucial mistake, was that they made the pens too expensive for middle-class America.

Nobody complained when EpiPens were $50 apiece. Anybody who has ever used one of these devices knows that you need to actually buy two at a time, just in case you don’t operate the initial one correctly in an actual emergency. It seems that they need to be replaced every year. A budget of $100 per year is very affordable for most people for a potentially life-saving medication.

Actually, for many of my patients, $100 can absolutely crush their monthly budget. When you make $8 per hour and have a family of 4, $100 may destroy the grocery budget, or the gas budget, or the clothing budget for a child. Think about the possibility of having two pens at the school and two pens at home: That’s $200 a month. That’s about 30 hours of work, or the majority of a work week simply for EpiPens. For a single mom with three children, the price of EpiPens in 2007 could potentially have been soul crushing.

Mylan’s CEO was making $2.5 million back then. That’s right: $2.5 million for access to a drug that costs less than a dollar a vial.

But that salary wasn’t enough. The greed became such that Mylan made middle-class America alter their budgets: And middle-class America sticks up for themselves.

So that’s the recipe, big pharma. Continue hiking drug prices and crushing poverty stricken family budgets. Their voice is quiet. But don’t make the medications too expensive for middle-class America, or you’ll make national news, and only hike the prices of drugs that insurance plans cover.

And hope to God that we never start sticking up for the most vulnerable people in society: the ones who worked 30 hours per year to pad your salary for a medication that you knew they absolutely had to have.

Justin Reno is a family physician.

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