money and tablets, drug prices, collusion

Americans are used to negotiating prices–some call it haggling–for big-ticket items like cars and houses. Sometimes parents arm-wrestle colleges over tuition aid. But rarely do we bargain over the price of a cup of coffee, a pair of shoes or prescription drug prices. That last item could be a big mistake.

Prescription Drug Prices Are Highly Variable:

It turns out that there is enormous variation in the prices that pharmacies in the same region may charge for an identical drug. This has been brought into sharp relief by an article published in JAMA Internal Medicine (online Nov. 15, 2016).

The authors investigated prices of generic drugs to treat heart failure in the city of St. Louis, Missouri. These medications are not optional: they are crucial for survival. But they are also not fancy new brand-name medications. They’ve been around for years, so doctors and patients both expect them to be affordable.

The investigators were inspired to collect data on drug prices when one of them got a call from a patient who couldn’t afford his heart pills. He had a bill for $100 at a local pharmacy. The doctor was startled, since he’d expected the bill would be closer to $5.

Investigating Prescription Drug Prices:

So he and his colleagues called pharmacies in two states in the greater St. Louis metropolitan area. They requested prices for three heart drugs: carvedilol, digoxin and lisinopril. Over 150 chain pharmacies and 22 independent pharmacies were queried.

The data they got were all over the map, with prices for a 30-day supply of digoxin, for example, ranging from $4 to $300. For the combination of all three drugs, often prescribed together, the lowest price was $12 and the highest was $397.58.

Pharmacy type, state, neighborhood and ZIP code were not consistently associated with the variation in price. This seemed to change with each individual store, and was not determined by dose or duration of prescription. According to the researchers:

“Only 1 chain had consistent pricing across its stores…In conclusion, generic drugs for HF [heart failure] show wide variability in pricing at the retail pharmacy level.”

Negotiating Prescription Drug Prices:

What can patients do when faced with such a chaotic situation? The first lesson is that you have to shop around. Prices may be vastly different between two pharmacies around the corner from each other.

The other lesson: hone your negotiating skills. That was perhaps the most surprising advice offered by Consumer Reports last summer (July 29, 2016).

Ask the pharmacist, “Is this your best price?” Some are prohibited from volunteering such information but can respond to a direct question. And certain pharmacies may be willing to match the lowest price you find elsewhere. Even though we shouldn’t have to haggle over the price of medications, what is at stake for heart failure patients is their life as well as their money.

The Downside of Shopping Around:

One disadvantage of shopping multiple drugstores for the best price is that the responsibility for keeping track of overlapping or interacting medications falls more heavily on the patient. Those who must use several pharmacies should always keep a complete list of their medicines and ask about interactions each time they get a new drug. It is also important for the prescriber to double check for drug incompatibility. Remind your physician or PA about all the medicines you are taking and make sure she verifies there are no dangerous interactions.

Shopping Online for Better Deals:

There is rarely a reason to shop online for generic drugs. That’s because U.S. prices are nearly as low as any place in the world. In the U.S. the generic drug business is cutthroat. Most of the generic drugs purchased in this country are now made abroad in countries like China and India. Insurance companies and third party payers often force pharmacies to purchase the lowest cost generics without requiring research on the reliability of the manufacturers. Of course, the investigators who carried out the recent research that was published in JAMA Internal Medicine found that even the cost of generic drugs can vary from pharmacy to pharmacy in the U.S.

If you are looking to purchase brand name products, you may be even more surprised by the difference in price. The people at recently analyzed some commonly prescribed medications that have a narrow therapeutic index (NTI). Such drugs should have little to no variability in quality because the dosage must be kept within a very narrow range.

In the U.S. the brand name anticoagulant Coumadin could cost more than three times the price in a Canadian pharmacy. There was an even greater price discrepancy between the heart drug Lanoxin when it was purchased in the U.S. vs. in Canada.

If you are struggling with sticker shock at the drugstore yourself, you may be interested in our Guide to Saving Money on Medicines. It is available online at In it, you’ll discover our ten tips for saving money, including shopping around, bargaining and checking to see if you qualify for free medicine.

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  1. Lynn
    Waxhaw, NC

    I went that route of going outside of Medicare for a cheaper price–until I discovered I was losing money by not paying into the deductible. The price of that drug and others would go down once I met the deductible for my Medicare Part D plan.

  2. Ann B.
    north carolina

    I’m bewildered at this column. A quick glance at the online Wal-mart $4/$10 drug list shows two of the three drugs mentioned at many doses. The Digoxin a more unusual drug, comes to a whopping $40 at most drugstores, even without getting an online coupon. Furthermore, Wal-mart will MATCH nearby store prices, so the total I calculate with no coupons and only a couple of phone calls is $48/month at Walmart. But Rite-Aid comes to only $10/month for Digoxin with their drug card which is free. So with two trips you can get this down to $18/month.
    I once was behind a customer who had a dentist’s prescription that cost $80, and was just an 800 mg ibuprofen! She said she couldn’t afford it, and I was horrified, having a large bottle of 200 mg ibuprofen in my cart for a dollar and change – she was delighted with this info. Doctors should know this stuff!

  3. Simon

    Go to GoodRx (google it) for an EXCELLENT search engine, to find local competitive pricing for drugs. I’ve used it several times, successfully. It works on your computer, or your smartphone.

  4. Carolyn
    Brookings, Oregon

    My thoughts are the flowing: GENERIC/ VS BRAND NAME OF ANY PRESCRIPTION DRUG IS NOT THE SMAE. PLEASE DO YOUR HOMEWORK. Why do you suppose the States of India, Africa, and Canada had banded them!

  5. jw

    Further, whether to pay cash or use insurance: if you have Medicare Part D (the prescription drug plan) and several of your normal meds are costly name brands, if it’s early in the year and the cash price for generics is even close to the cost you’d pay using insurance, it might be wise to pay the cash price wherever possible to do whatever is reasonable to avoid going into the “donut hole.”

    When we use our insurance, both what the patient pays AND what the insurance says the med cost them count toward the donut hole threshold. When you pay cash without using insurance, NOTHING counts toward amount at which we’ll go into the donut hole.

    It seems ridiculous to be paying for insurance that you have to choose when to use, and it’s true that the % of the cost the insured has to pay while in the gap (the donut hole) decreases every year, but it’s a fact of life under Medicare Part D.

  6. Lola
    South Florida

    One thing that has been a real eye-opener is the inability to use any coupons from pharmaceutical companies if you are on Medicare. No one has ever been able to explain the rationale, but I could have saved hundreds of dollars this past year.

  7. Joseph Marovich

    Thank you for publishing and making available the “Guide to Saving Money on Medicines”. After downloading it I was astonished at the differences in pricing for any one drug. Particularly interesting was your section on buying drugs from Canada. The information you provided, including how to check out the Canadian pharmacies, and the websites for us to investigate is invaluable. Thanks for the great service to your subscribers.

  8. Tim
    Long Island, NY

    I almost dropped my teeth when I saw how much my part D plan, Silverscript paid for 90 days of Metformin ER. Would you believe $14, 953!? I paid $10 when I picked it up, but I saw the insurance company paid the $14,953 ! I visited the CVS and discovered that it wasn’t a simple mistake and the “full price” was something like $18,000 !!! Some folks would say ..fine as long as you didn’t have to pay it, but I look a bit deeper. With the C.M.M.I. looking over everyone’s shoulder, how long will it be before they decide I (and others like me) are just too expensive to keep alive ??? Turns out this generic came from a company in India. That is wrong on so many levels! I called my Senator and Reps office but never heard back…but it was election season. If a human being at People’s Pharmacy gets a chance to read this I’d like to hear back from you with your thoughts on this.

  9. don
    Melbourne FL.

    Why is the word “GREED” not mentioned in the article??

  10. Bill

    There’s a simple solution to drug prices: make it legal for individuals, companies, etc. to import drugs from other countries and using those country’s drug validation system. Immediately we gain the advantage of those country’s bargaining powers. Why hasn’t this been done? Because congress gets large donations from the drug companies. This is a great opportunity for next president Trump to score big with the people, not including congress or the pharmas.

  11. D'Ann

    It really is important to ask the pharmacist if it’s cheaper to buy the drug for cash or with your drug plan. My husband’s last Rx refill was ⅓ HIGHER if he used his insurance.

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