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In a weird paradox, it's never been cheaper -- and more expensive -- for men to treat themselves with sildenafil (Viagra), the mainstay of erectile-dysfunction therapy. And herein lies a tale about the bizarro world of drug pricing.

Generic versions of sildenafil cost as little as per typical 50-mg dose in the U.S. when 30 pills are purchased, according to GoodRx.com. At that price, the doses needed to power a month's worth of daily intimate encounters add up to just $13.20, less than a Chipotle steak burrito with guacamole and a drink.

But equivalent brand-name Viagra pills cost at least $67.12 each, or That's a remarkable markup of over 150 times the generic price, even though the pills share the same active ingredient and work the exact same way.

A MedPage Today investigation found that Viagra is perhaps the most extraordinary example of a curious phenomenon in the world of drug pricing -- brand-name medications whose prices go up despite the arrival of stiff competition from much-cheaper generics.

This isn't the way competition in capitalism is supposed to work, and it's hardly healthy for consumers. But some pharmaceutical companies are banking big-time on brand-name loyalty and ignorance about generics, and no one is going to tell them to knock it off.

"Companies can decide the price of drugs in the U.S. private sector without any constraints," , a professor of pharmacy who studies drug pricing at Chapman University in Irvine, California, said in an interview with MedPage Today. "We may need public health campaigns explaining the value of generic drugs so patients have information and can decide if they want to expend thousands of dollars out-of-pocket to get the brand drug instead of the low-cost generic."

Viagra: Still the ED Leader After All These Years

Sildenafil entered the U.S. market as Viagra in 1998 and instantly revolutionized impotence care by giving men a convenient alternative to less-than-appealing erectile dysfunction (ED) treatments like penis pumps, injections, and implants. The little blue pill became a household name thanks to celebrity endorsements, TV commercials, and the world's most famous side effect. (Sorry, gentlemen, isn't all it's cracked up to be.)

Nearly a quarter-century later, sildenafil has spawned a handful of competitors, notably tadalafil (Cialis) and vardenafil (Levitra), but it remains the undisputed king of ED care in the U.S., according to .

"Viagra is still often the first drug prescribed because everyone knows about it, and even primary care docs are comfortable writing it. Also, the evidence in the literature largely supports it being the strongest and most efficacious" of the main ED drugs, University of Utah urologist , told MedPage Today. "There are strong considerations for Cialis as well, but it's less popular because fewer physicians and patients really know how to use it."

Patent expiration, the perennial scourge of brand-name drug manufacturers, came for Viagra in the late 2010s. Pfizer and Teva Pharmaceuticals in late 2017, and other companies started offering generic products the following year. That's when the world shifted for patients.

From December 2017 to June 2021, the list price for six tablets of 100 mg of generic sildenafil (the most common prescribed amount) fell by 98% from $265 to $4, according to provided by GoodRx.com. Over that same time, the average list price for the equivalent doses of Viagra grew by 27% from $369 to $467.

"We're still seeing spikes with Viagra every year, while sildenafil has plummeted in price," GoodRx.com director of research Tori Marsh, MPH, told MedPage Today.

Physicians are mystified. "I have no idea why there continues to be that large price gap. There is just no good reason," endocrinologist , chief of medicine at the University of Washington Medical Center, told MedPage Today.

Meet the 'Generic Competition Paradox'

Markups for brand-name drugs facing generic pressure aren't a new phenomenon. In fact, they're standard. "The idea is that once a generic enters the market, the prices of the generic go so low in comparison with the brand that it doesn't make sense for the brand to compete based on price," Seoane-Vazquez said.

This is why shelves are filled with competing over-the-counter products that are essentially the same except one costs more and has a familiar name attached -- Bayer, Tylenol, Afrin, Metamucil. The list goes on.

On grocery shelves, the big difference from pharmaceuticals is that no one requires low-priced supermarket brands to taste the same as Ragu pasta sauce or Kellogg's Corn Flakes. In contrast, equivalent brand-name and generic drugs are mandated by law to be identical -- mostly. , "a generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used."

There are some differences: Brand-name drugs may have different inactive ingredients than the equivalent generics, and they typically look different due to trademarks that protect their appearance. Among sildenafil pills, for example, only brand-name Viagra can be both blue and diamond-shaped. There can also be in the bioavailability of a drug's active ingredient.

It's not easy to understand exactly how much the typical customer pays for brand-name and generic sildenafil. For one thing, list prices don't truly represent the amount that customers pay for drugs. Pharmacies discount the prices of medications, and consumers can get coupons from a variety of sources such as pharmaceutical companies and GoodRx.com. To make things even more complicated, insurers , and even if they do they're not likely to pay for expensive brand names when generics are available.

One thing is clear: Viagra's markup is consistently high. According to GoodRx.com, the cheapest price in the San Diego area for six tablets of 100 mg generic sildenafil is at Ralphs supermarkets with a free coupon. The least expensive price for the equivalent amount of brand-name Viagra is at all 10 pharmacy outlets listed with a free discount -- a markup of 42 times.

When It Comes to Humongous Markups, Viagra Stands Tall

Viagra isn't alone in boosting its price in response to competition. For nearly 3 decades, researchers have chronicled the "generic competition paradox": Drugmakers actually boost the prices of their brand-name medications when cheaper generics enter the market.

The most likely brand-name drugs to do this are those with high name recognition and intense generic competition, Seoane-Vazquez said. (Viagra fits this description.) Other types of drugs are less likely to raise their prices in response to generics. These, he said, include drugs such as biologics with limited competition, drugs used in hospitals and physician offices, and drugs with relatively low name recognition such as some antibiotics.

In a bit of good news for consumers, the generic competition paradox phenomenon appears to be less common than it used to be, according to researchers with , a consulting firm. They examined 78 drugs whose patents expired from 2009 to 2020 and found that their prices tend to stabilize after generic equivalents appear and not go up at a fast clip.

This marks a significant shift from the past, the researchers argue in published in the International Journal of the Economics of Business. They write: "We believe the results in our paper reflect the brand-name pharmaceutical companies' acknowledgement of the ever-changing competitive landscape and their attempt to moderate price increases in response to the ever-growing market presence of generics."

As for Viagra, it's an outlier. "Its price did keep moving up even after the generic entry, with the annualized rate of change at 9.5% before generic entry and 15.4% afterwards," study co-author Yong Xu, a managing director at StoneTurn, told MedPage Today.

The price markup of Viagra since it gained generic competition appears to be an outlier among ED drugs specifically and prescription drugs in general.

Thirty tablets of a typical 5-mg dose of tadalafil, for example, cost as little as in the generic form but jumps to at least as brand-name Cialis, per GoodRx.com. (Both prices require coupons for discounts.) While that markup is hefty -- the brand-name is 33 times the price of the generic -- it's not in the league of Viagra's markup for a 30-day supplies of 100-mg pills. Eli Lilly and Company, the manufacturer of Cialis, didn't respond to questions from MedPage Today.

Marsh, the director of research at GoodRx.com, said there's also notable demand for the brand-name versions of the thyroid drug levothyroxine and the blood thinner warfarin even though much-cheaper generics are available. Again, however, the markups aren't anywhere as near as extreme as Viagra's.

Thirty tablets of 50 mcg levothyroxine and 30 tablets of 5 mg warfarin cost as little as $4 at Walmart for consumers without insurance, per GoodRx.com. The brand-name equivalents of these typical doses cost at least $45.41 for Synthroid and $75.79 for Coumadin, respectively.

Pfizer Spins Off Viagra, and the New Company Struggles

Why is Viagra's price so astronomically high? "They're obviously doing it because they can," suggested Johns Hopkins Medicine primary care physician who told MedPage Today that he tries to talk his patients out of paying for unnecessarily expensive brand-name drugs.

MedPage Today sent a series of questions about the drug's pricing to the new maker of Viagra. In 2020, Upjohn -- a unit of Pfizer that manufactured Viagra and other off-patent drugs -- merged with drugmaker Mylan to become a new firm called . It now makes both brand-name and generic Viagra.

Viatris declined to explain its pricing and instead sent a statement noting it "offers both branded and generic options for patients taking this medication. ... We encourage patients to work with their healthcare professionals to determine the best treatment option for them." The company also noted that eligible patients can save on brand-name Viagra via a "savings card."

The reverse of the Viagra pricing question is this: Why do men still insist on paying exorbitant prices for a brand-name drug when they could save hundreds or thousands of dollars a year? "I do have some patients who insist on the brand name because they believe that it works better than cheaper alternatives," said Pastuszak. "As you can imagine, this is difficult to prove," especially considering "the potential for a placebo effect."

Seoane-Vazquez said the high price itself can be a draw: Customers might think "there must be something in the drug that costs $50 instead of 50 cents." And, he said, "drugs often fail to work as intended. When a brand drug fails, patients may think that the drug does not work and try other alternatives. When a generic drug fails, patients may think that something is wrong with the drug and ask to switch to the brand."

He added that "brand names and higher prices are associated with value, and using expensive brands is a demonstration of wealth. So it is also possible that patients use the brand to demonstrate that they are wealthy."

Brand-Name Markups: Why They Matter

Viagra's worldwide revenue has since generics appeared, and the drug's unusual pricing strategy doesn't appear to be setting the world on fire for its new manufacturer. In fact, Viatris has struggled since its inception. In a March 2021 article, called it "the worst-performing stock of the S&P 500 Index so far this year" and noted that "analysts are urging investors to steer clear." The stock continues to perform poorly.

A gigantic markup is no boon for Viagra-centric consumers, either. But is this kind of price manipulation actually harmful? Yes, says University of Southern California health economist

The discounted prices of Viagra mask the reality that many customers don't know they can save money off the list prices of brand-name drugs, he told MedPage Today. "If you set a cash price high, there are some consumers who will pay that price." Low-income people without insurance are especially vulnerable to paying full price, he said: "The cash payer, the uninsured, has historically gotten screwed." (The of a 30-day supply of 50 mg of Viagra, per GoodRx.com, ranges from $2,468 to $3,099. The discount price is $2,013.70 across the board.)

Viagra buyers who pay the Cadillac brand-name prices may also fail to get a bang for their super-sized buck. As many as 50% of men who use sildenafil don't stick with it in the long term, University of Washington urologist , told MedPage Today: "It doesn't work, or it has side effects, or they don't want to be on a medicine." Alternatives include other ED drugs or hard-core treatments such as penis injections or implants. Some men just give up, Wessels said.

Researchers are that will work better than the current ED treatment options. For now, though, even a price markup to beat all price markups is no guarantee that a man will get the sexual boost he seeks. He may just end up with a $2,013.70 hole in his bank account.

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