'Disturbingly' High, Variable Costs Seen for Generic HF Meds

Marlene Busko

November 21, 2016

NEW ORLEANS, LA — Although it's commonly thought that in the US, uninsured patients can buy a 30-day supply of a generic heart-failure drug for as little as $4, a price that low may be the exception rather than the rule, suggests a new analysis [1].

It found that prices for uninsured patients for three generic drugs commonly given based on the HF guidelines—lisinopril, carvedilol, and digoxin—varied widely in pharmacies throughout Illinois and Missouri and that prices for the same drug also varied widely.

A month's supply of the three generic drugs together cost a median of $70, but there was a 30-fold range in the price for the combination. A month's supply of digoxin, which is a much older drug than the ACE inhibitor and beta-blocker, was the priciest at $306 for the high-dose versions.

"We have no reason to believe that somehow [these findings] just apply to this little segment on either side of the Mississippi," Dr Paul J Hauptman (Saint Louis University School of Medicine, Missouri) told heartwire from Medscape prior to his presentation of the study here at American Heart Association (AHA) 2016 Scientific Sessions.

These very sick patients "aren't in the state physically, mentally, or emotionally to be calling three, four, five, or six pharmacies" to find affordable prices, Zackary D Goff (Saint Louis University School of Medicine) lead author on the poster, added.

The study was also simultaneously published online in JAMA Internal Medicine.

Other experts agree that these findings are "disturbing," and clinicians need to be more aware of these widespread, high prices of generic HF drugs. An app can help them find out the prices of these drugs in nearby pharmacies.

"Surely You Jest!"

The study was prompted by a young uninsured patient with heart failure who was prescribed the usual heart-failure medications including digoxin and "called the office and said he filled all the prescriptions except digoxin, which cost $100," Hauptman related. "My nurse told me this, and I said, 'Surely you jest; he probably misunderstood something. Why don't we just call the pharmacy and confirm the $100?' " It really was $100, and the researchers wondered whether this high price was common.

Hauptman and colleagues aimed to determine the retail prices for uninsured patients for low and high doses of generic digoxin, lisinopril, and carvedilol in independent and chain pharmacies, in 55 zip codes in a region comprising eastern Missouri and southern Illinois, centered on metropolitan St Louis.

In May 2016, they phoned 200 pharmacies in this region to ask for the prices for a 30-day and a 90-day supply of 0.125-mg/day and 0.250-mg/day digoxin, 10-mg/day and 40-mg/day lisinopril, and 6.25-mg twice-daily and 25-mg twice-daily carvedilol for a person without health insurance.

A 30-day prescription is more common for uninsured patients, whereas insured patients may have a 90-day prescription, Hauptman explained. The study did not include mail-order pharmacies because most uninsured or underinsured patients do not have access to this option, he added.

The researchers obtained prices from 153 chain pharmacies and 22 independent pharmacies.

The differences between the lowest and highest prices for a month's supply of each individual drug or for all three drugs were striking.

Median Prices for 30-Day Supply of a Generic HF Drug (Range), $

  Digoxin Lisinopril Carvedilol
Low dosea 40.19 (12.19–94.99) 9.99 (3.00–80.59) 14.86 (4.00–135.99)
High doseb 40.19 (4.00–305.99) 14.18 (4.00–87.59) 14.47 (4.00–73.81)
0.125-mg/day digoxin, 10-mg/day lisinopril, 6.25-mg twice-daily carvedilol
0.250-mg/day digoxin, 40-mg/day lisinopril, 25-mg twice-daily carvedilol


Median Prices for 30-Day Supply of Three Generic HF Drugs (Range), $

  Digoxin, Lisinopril, and Carvedilol
Low dose* 67.98 (20.19–256.77)
High dose** 70.68 (12.00–397.58)
0.125-mg/day digoxin, 10-mg/day lisinopril, 6.25-mg twice-daily carvedilol
0.250-mg/day digoxin, 40-mg/day lisinopril, 25-mg twice-daily carvedilol

Only three pharmacies sold a month's supply of digoxin for $4, and only four in 10 pharmacies sold a month's supply of lisinopril or carvedilol for this price.

Only three pharmacies (1.7%) sold a 30-day supply of all three drugs for less than $25, and only nine pharmacies (5.3%) sold this combination for less than $100.

Prices varied widely in both independent and chain pharmacies, although one chain had consistent pricing across its stores.

Prices were similar in the two states and in pharmacies where the median annual household income was high (n=27, $85,883), moderate (n=79, $59,347), or low (n=69, $31,032).

The findings were similar for the 90-day supplies.

There were seven generic drug manufacturers for digoxin, nine for lisinopril, and eight for carvedilol, "so theoretically there's a lot of competition, but nevertheless, the costs are still high," said Hauptman.

"A given drug takes a journey from the generic manufacturing company to a distributor/wholesaler a to retail pharmacy and then to the patient, and at any step along the way there can be price hikes," he noted. "There's no transparency—it's hard to know where those price hikes are coming from."

More research beyond the scope of this study is needed to unravel the reasons for these high, variable prices for generic HF drugs and the subsequent effect on adherence and clinical outcomes, Hauptman said.

Others Weigh in; an App May Help

"Most patients do not shop around for the best drug price and [just] go to the pharmacy near their house," Dr Rita F Redberg (University of California, San Francisco), editor, JAMA Internal Medicine noted to heartwire .

Cardiologists need to be aware of these "disturbing" wide price variations and high prices for these generic HF drugs, "so that we can work with our patients to increase the affordability of their drugs, which will increase adherence," she continued.

"If patients have to choose between paying their rent and buying their medications, it will lower adherence for these necessary [effective] drugs."

Clinicians seem to be aware of this problem, "but probably not to the extent that we should be, because we are somewhat insulated from it," Dr Larry Allen (University of Colorado, Denver) commented to heartwire . "We write a prescription, and then patients, pharmacists, and nurses often clean up most of the confusion and challenges when the cost is high."

Although there is no reason to think that these high, variable prices of generic HF drugs are unique to St Louis, it would be interesting to check prices in other parts of the country, said Redberg. "This is a big problem, [since] there are 7.3 million Americans with [all types of] cardiovascular disease that are uninsured."

An app may help clinicians find nearby pharmacies with lower prices that uninsured patients can afford. "I have been using the app GoodRx for over a year," Allen said. "You should try it: download the app, type in 'digoxin,' and it shows you out-of-pocket costs for all the nearby pharmacies."

Hauptman reports serving as a consultant to St Jude Medical, Sensible Medical, Relypsa, Amgen, and Corvia; participating in speaker bureaus for Relypsa, Amgen, and Otsuka, and receiving research grants from Alnylam, and the National Heart, Lung, and Blood Institute. The coauthors have no relevant financial relationships.

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