Access to Health Care in the U.S.-Mexico Border Region: Models, Research, Policy and Action Crossing the Border for Prescription Drugs Howard J. Eng, RPh, MS, DrPH Southwest Border Rural Health Research Center Mel and Enid Zuckerman Arizona College of Public Health, Rural Health Office University of Arizona October 15, 2004

Presentation Overview Rising Health Care Costs in the United States U.S.-Mexico Border Top 10 Prescription Drug Price Comparisons: U.S., Canada, and Mexico in 1999 FDA International Flyer: “Purchasing Medication Outside the United States” U.S. Prescription Drug Availability in Mexico FDA Guidance for Coverage of Personal Importation Recommendations Arizona Accepts Mexican Prescriptions

This boundary fence is seen from Nogales, Arizona as you go into Nogales, Sonora. The U.S.-Mexico Border area is defined as 100 kilometers (62 miles) north and south of the Border and close to 2,000 miles in length. Photo: Community Access Program of Arizona (CAPAZ)

Nogales, Sonora houses seen from a hill in Nogales, Arizona. About 13 million people reside along the U.S.-Mexico Border region (6.4 million in Mexico and 6.6 million in the U.S.). Considered together, U.S. border communities are 50% Hispanic, although in cities like Nogales, Arizona the proportion is much greater, about 93.5% Hispanic. Photo: Community Access Program of Arizona (CAPAZ)

Vehicles and pedestrians crossing into Algodones, Mexico from Andrade, California during the winter months. Estimates on U.S.-Mexico border crossings range from million legal crossings in each direction per year, or between 800,000 and 1.1 million legal border crossings per day. Photo: Community Access Program of Arizona (CAPAZ)

The Plaza Flamingo sign shows some of the many health care services offered in the small town of Algodones. According to a 1997 Health Care Services Report completed for Arizona’s Governor Jane Hull, 5% of border crossings were for the purchase of medical and dental services.* Photo: Community Access Program of Arizona (CAPAZ) * Health Services: Strategic Economic Development Vision for the Arizona-Sonora Region, October 1997

Price Comparison of Top 10 U.S. Rx Drugs [USA Today November 10, 1999] (1) DrugConditionU.S.CanadaMexico PrilosecHeartburn/ Ulcer $3.31 $1.47$0.99 ProzacDepression $2.27 $1.07$0.79 LipitorHigh cholestrol $2.54 $1.34$3.60 PrevacidUlcer $3.13 $1.34$1.18 EpogenAnemia$23.40$21.44N/A

Price Comparison of Top 10 U.S. Rx Drugs [USA Today November 10, 1999] (2) DrugConditionU.S.CanadaMexico ZocorHigh cholestrol $3.16$1.47$3.66 ZoloftDepression$1.98$1.07$1.96 ZyprexaMood Disorder $5.27$3.39N/A ClaritinAllergies$1.96$1.11$0.92 PaxilDepression$2.22$1.13$1.83

U.S. residents purchasing medications in Algodones, Mexico. During the winter months Yuma, Arizona is populated by “snowbirds” (people who live in one state, but spend their winters in a state with a warmer climate). Many of Yuma’s snowbirds go to Algodones, Mexico to purchase their medications. Photo: Community Access Program of Arizona (CAPAZ)

FDA Purchasing Medications Outside the United States Informational Flyer (1) Some medications and their ingredients, legal in foreign countries, may not be approved for use in the United States. The product label, including instructions for use and possible side effects, may be in a language the user does not understand (e.g., Mexico - Spanish). Further, labeled directions may not be approved for use in the United States. It can be dangerous to take some medications without medical supervision (This is the primary reason for placing medications on prescription drug status in the United States). FDA cannot assure that products not approved for sale in the U.S. conform with the manufacturing and quality assurance procedures mandated by U.S. laws and regulations. Source: FDA January 12, 1994 Informational Flyer to State Boards of Pharmacy and State Drug Programs.

FDA Purchasing Medications Outside the United States Informational Flyer (2) Some medications may be counterfeit versions of U.S. approved products. Treatment of an adverse drug reaction can be delayed or hindered without sufficient product information. Possession of certain medications without prescription from a physician licensed in the United States may be a violation of state and local laws. Source: FDA January 12, 1994 Informational Flyer to State Boards of Pharmacy and State Drug Programs.

U.S. Prescription Drug Availability in Mexico (Diccionario de Especialidades Farmaceuticas 2003) U.S. Prescription Drug NameMexican Prescription Drug Name Premarin 0.3 mg (Tablet) Premarin mg (Tablet) Premarin 0.9 mg (Tablet) Premarin 1.25 mg (Tablet) Premarin 2.5 mg (Tablet) ****** NA ******* Premarin mg (Tablet) ****** NA ******* Zantac 150 mg (Tablet) Zantac 300 mg (Tablet) Azantac 150 mg (Tablet) Azantac 300mg (Tablet) Lanoxin mg (Tablet) Lanoxin 0.25mg (Tablet) Lanoxin 0.50 mg (Tablet) ****** NA ******* Lanoxin 0.25 mg (Tablet) ****** NA *******

FDA Guidance for Coverage of Personal Importation U.S. Customs and Border Protection: May allow an individual entering the United States to import a three month supply of an unapproved drug if all the following conditions are met:  The intended use of the drug is for a serious condition for which effective treatment may not be available domestically.  The drug will not be distributed commercially by the importer.  The product is not considered to represent an unreasonable risk.  The individual seeking to import the product affirms in writing that the drug is for his or her own use.  Provides the name and address of the U.S. licensed doctor who is responsible for his or her treatment with the product or  Provides evidence that the product is for the continuation of a treatment begun in a foreign country. Source: U.S. Custom and Border Protection http://

Recommendations The use of medications purchased in Mexico needs to be monitored regularly by a medical doctor to assure therapeutic effectiveness. There must be a prescription for each medication purchased in Mexico in order to avoid any problems with U.S. Customs. Since not all drug strength and dosage forms are available in Mexico and Mexican pharmacists are not generally trained in therapeutics, the buyer needs to make sure he or she is purchasing the right drug. The buyer may not purchase more than a 90 day supply. Buying more than the limit may be considered a violation of the law by the U.S. Customs inspector. It is important to select the right Mexican pharmacy to assure that the medications are stored properly and are not counterfeits.

Arizona Accepts Mexican Prescriptions Arizona Board of Pharmacy regulation does not prohibit a pharmacist, or an intern under a pharmacist’s supervision, from filling a new written prescription order for a drug or device issued by a medical practitioner licensing board of Canada or the Republic of Mexico. –No refills –Mexican State Department of Health (e.g., Soñora) provides the approved prescriber names to Arizona State Board of Pharmacy. The proprietor, manager, or pharmacist in charge of the pharmacy shall keep a separate record of prescriptions filled. A pharmacist or intern shall not fill a prescription order issued by a medical practitioner licensed by the appropriate licensing board of Canada or the Republic of Mexico for a controlled substance. Source: Arizona Board of Pharmacy Rules and Statutes, Title 32 Professions and Occupations, Chapter 18 Pharmacy, Article 3 Regulation,

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Contact Information Howard J. Eng, MS, DrPH Director Southwest Border Rural Health Research Center Rural Health Office Mel and Enid Zuckerman Arizona College of Public Health 2501 E. Elm Street Tucson, Arizona