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Wide Price Swings Found in Generic Heart Failure Drugs


A study inspired by a patient who could not afford his heart medication shows that there was no pattern to price variability for a common regimen to treat heart failure, which could contribute to poor adherence.

A patient’s complaint that he couldn’t afford his heart medication led a group of researchers at the Saint Louis University School of Medicine to explore regional pricing patterns of commonly prescribed generic drugs.

What they found alarmed them–it turned out there were no patterns at all. Patients who lacked pharmacy benefits might be charged between $12 and $400 for the combined price of digoxin, lisinopril, and carvedilol, a typical regimen for heart failure.

Nothing seemed to explain the variation–not the pharmacy type, nor the location, nor the income of the neighborhood. Senior author Paul J. Hauptman, MD, a cardiologist and professor of medicine at Saint Louis University, said many patients take 3 to 5 drugs to treat heart failure; thus, this pricing cacophony creates huge adherence problems among lower-income patients, especially if they lack a prescription drug benefit.

“It’s not reasonable to expect patients who are sick and of limited financial means to call or visit a dozen pharmacies to get the best price,” he said in a statement. “What is more likely to happen is that patients visit a pharmacy and find out that the drug is too expensive, so they don’t fill the prescription and therefore do not garner benefit from guideline-directed medical therapy.”

The problem of rising generic drug prices has gained attention from consumers and the Congress. Federal data released Monday show 9 of the 20 drugs with the biggest increases for Medicaid in 2015 were generic drugs. A commentary in The American Journal of Managed Care in September 2014 questioned whether the increased practice of assigning some generic drugs to non-preferred status occurred not because there were lower cost choices available, but simply because the drugs were expensive.

In the poster session, co-author Zackary D. Goff explained how the study began one day in the clinic when a 25-year-old patient told Goff and Hauptman his digoxin cost $100, and he couldn’t afford it. The doctors didn’t quite believe him. But Goff said when they looked up the price at the patient’s pharmacy, his story held up.

Soon, a study was born. The research team phoned 200 pharmacies across 55 ZIP codes in the greater Saint Louis area and collected pricing data from 175. They collected prices for 2 doses of digoxin (0.125 mg and 0.25 mg), 2 doses of Lisinopril (10 mg and 40 mg), and 2 doses of carvedilol (6.25 mg and 25 mg) They priced 30-day and 90-day supplies, and recorded pharmacy type (chain vs independent, the pharmacy ZIP code, and obtained the median income for the ZIP code through US Census Bureau data.

Of the 175 pharmacies that provided prices, 153 were part of chains. Median income of all ZIP codes was $53,122, with a range of $10,491 to $112,017. Prices ranges were significant:

·         A combination of all 3 drugs in the low dose ranged from $20.19 to $256.77, with the median at $67.98.

·         A combination in the high dose ranged from $12.00 to $397.58, with the median $70.68.

·         Digoxin was consistently the most expensive.

·         Only 1 of the 3 major chains had consistent pricing across all its retail stores. Goff said because the sample is small, the team is identifying which chain had consistent pricing.

The implications for adherence may be greatest for patients living in low-income areas, the authors wrote, because patients may not have easy access to lower-priced pharmacies.

Tuesday’s study is simultaneously published in JAMA Internal Medicine. Goff noted that while double-checking prices in advance of publication, some had already changed.

As the authors note their research letter, price variability in heart medications has implications because the number of patients who are affected. Heart disease remains the nation’s number one killer, and an estimated 7.3 million Americans with cardiovascular disease are uninsured, they write.


Hauptman PJ, Goff ZD, Vidic A, et al. Variability in retail pricing of generic drugs for heart failure [published online November 15, 2016]. JAMA Intern Med. doi:10.1001/jamainternmed.2016.6955.


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