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Many of the most expensive generic drugs aren't available at direct-to-consumer (DTC) pharmacies like Mark Cuban Cost Plus Drugs or Amazon, a cross-sectional study showed.

About 20% of the 100 most expensive generic drugs -- treatments for HIV, cancer, or multiple sclerosis, for instance -- weren't available at any of five of the most common DTC pharmacies, Hussain Lalani, MD, MPH, MSc, of Brigham and Women's Hospital in Boston, and colleagues .

Common, inexpensive generics like blood pressure drugs and statins, on the other hand, were widely available at these pharmacies, they found.

"For the more expensive specialty generic drugs, where patients probably stand to benefit the most, it's far more variable in terms of whether they're available," co-author Benjamin Rome, MD, MPH, also at Brigham and Women's Hospital, told MedPage Today in an interview.

Even when those expensive generics were available at these DTC pharmacies, the lowest price for each drug also varied widely, Rome said.

"It wasn't true that you could always go to Costco, or you could always go to Mark Cuban's pharmacy, and that would always have the lowest price," Rome said. "If you're a patient and you're seeking the best price, you would still have to shop around."

That poses a "big barrier," to DTC pharmacies being helpful for competing on generic drug prices, he said. "You have to shop around, find the best price, get your doctor to send the prescription to the right pharmacy, and then the next month, the prices might change, and you have to shop around again."

"That's a ton of work that I don't think consumers are ready for or equipped to handle," Rome continued. "It also creates equity concerns for patients who are vulnerable and don't have the resources or knowledge to do that sort of shopping."

For their study, Lalani and colleagues looked at the availability and pricing of 100 of the most expensive generic drugs and 50 of the most commonly used generics at five national DTC pharmacies: Amazon, Costco, Mark Cuban Cost Plus Drugs, Health Warehouse, and Walmart. They assessed those companies' websites in April and May 2023.

They determined the most expensive and most common generics by looking at Medicare Part D data from 2020. They then compared pricing info to retail pricing information from GoodRx.

The average spend per patient in Medicare Part D in 2020 on expensive generics was around $16,000, and a median of 3.3 million patients filled a prescription for each common generic that year.

Overall, 80% of expensive generics and 98% of common generics were available at one or more DTC pharmacies, they found.

Expensive generics were available at an average of 1.9 of the five pharmacies compared with 4.1 for common generics (P<0.001), they reported.

Among the expensive generics that were available, 47% had the lowest cost at Amazon, 26% at Mark Cuban Cost Plus Drugs, 14% at Health Warehouse, and 13% at Costco, they reported.

Among the common generics that were available, 31% had the lowest prices at Costco, 27% at Amazon, 20% at Walmart, 12% at Health Warehouse, and 10% at Mark Cuban Cost Plus Drugs.

The median cost savings for expensive generics was $231, or about a 76% discount, they found, with a comparable (75%) discount for common generics -- though that translated to a median savings of just $19.

Lalani and colleagues called for more transparent prices at traditional retail pharmacies, as well as better tools to help patients and prescribers know the true costs of medications.

"The complexity of the current retail pharmacy and [pharmacy benefit manager] PBM space is at fault here," Rome said. "We want this to be a streamlined process so that no matter where you want to fill the medicine, you should be getting competitive pricing."

He called for "fixing the existing system to make sure that the prices that patients are paying are real competitive prices, not inflated prices that are being skimmed off the top through multiple parts of the supply chain like the pharmacy benefits managers."

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