Availability and Cost of Expensive and Common Generic Prescription Drugs: A Cross-sectional Analysis of Direct-to-Consumer Pharmacies

Abstract

Background

Direct-to-consumer (DTC) pharmacies sell generic prescription drugs, often at lower prices than traditional retail pharmacies; however, not all drugs are available, and prices vary.

Objective

To determine the availability and cost of generic drugs at DTC pharmacies.

Design

Cross-sectional study.

Setting

Five national DTC pharmacies in April and May 2023.

Participants

Each qualifying form of 100 generic drugs with the highest cost-per-patient (expensive) and the 50 generic drugs with the highest number of patients (common) in Medicare Part D in 2020

Main Measures

Availability of these drugs and the lowest DTC pharmacy price for a standardized drug strength and supply (e.g., 30 pills), compared to GoodRx retail pharmacy prices.

Key Results

Of the 118 expensive generic dosage forms, 94 (80%) were available at 1 or more DTC pharmacies; out of 52 common generic dosage forms, 51 (98%) were available (p < 0.001). Of the 88 expensive generics available in comparable quantities and strengths across pharmacies, 42 (47%) had the lowest cost at Amazon, 23 (26%) at Mark Cuban Cost Plus Drug Company, 13 (14%) at Health Warehouse, and 12 (13%) at Costco; for 51 common generic formulations, 16 (31%) had the lowest cost at Costco, 14 (27%) at Amazon, 10 (20%) at Walmart, 6 (12%) at Health Warehouse, and 5 (10%) at Mark Cuban Cost Plus Drug Company. For the 77 expensive generics with available GoodRx retail pharmacy prices, the median cost savings at DTC pharmacies were $231 (95% CI, $129–$792) or 76% (IQR, 53–91%); for 51 common generics, savings were $19 (95% CI, $10–$34) or 75% (IQR, 67–83%).

Conclusions

Many of the most expensive generic drugs are unavailable at direct-to-consumer pharmacies. Meanwhile, less expensive, commonly used generics are widely available, but drug prices vary by pharmacy and savings are modest, requiring patients to shop around for the lowest cost.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-024-08623-y.

In the USA, competition among interchangeable generic drugs is the primary mechanism for controlling high prescription drug prices. After a period of market exclusivity for brand-name drugs, typically lasting 12 to 17 years, generic drugs provide competition, and sufficient competition can lead to price reductions of 80% or more for small molecules.^1–4 All US states allow pharmacists to automatically substitute Food and Drug Administration (FDA)–approved generics in place of prescriptions for brand-name drugs.⁵ As a result, generic drugs account for 90% of prescriptions filled but only 20% of overall prescription drug spending.^1,6,7 For insured patients, out-of-pocket costs for generics are typically low. For example, those with employer-sponsored coverage pay an average copayment of $11 for the first tier of generic medications.⁸

In some cases, however, generic drug markets have been characterized by limited competition, shortages of active pharmaceutical ingredients, or complex supply chains leading to prices paid by patients and insurers that greatly exceed the cost of manufacturing the drug itself.^9,10 In recent years, prices for some inexpensive generics have increased suddenly; from 2014 to 2017, 1 in 5 generic drugs doubled in price during the course of 1 year.¹¹ Whatever the origin of the high generic prices, the outcome is that prescription drugs are less affordable to patients who need them.^12,13 Patients most affected by high generic drug prices include the nearly 30 million uninsured Americans and the 49 million Americans enrolled in high-deductible health plans, which require patients to pay the full cost of drugs until they reach a minimum deductible of $1500 per person or $3000 per family in 2023.^14–16 Overall, up to 1 in 3 Americans struggle to afford their medicines.^17,18

When generic medicines are unaffordable, patients seek alternatives. Direct-to-consumer (DTC) pharmacies are one potential solution, allowing patients to purchase drugs directly without using health insurance. These pharmacies frequently advertise consumer prices far below retail prices at traditional chain pharmacies.^19,20 DTC pharmacies purchase prescription drugs from generic manufacturers or wholesalers and sell them to patients either in-store or by mail. Drug prices at DTC pharmacies are posted transparently, and patients with insurance, typically, must forgo coverage when purchasing drugs. Some DTC pharmacies are branches of traditional pharmacies (e.g., Walmart, Costco) while others are independent entities, such as the Mark Cuban Cost Plus Drug Company (MCCPDC).^19–24

In the last few years, DTC pharmacies have garnered substantial public attention.^22,25,26 However, it remains unclear how useful these pharmacies are for patients, both in terms of the availability of drugs and the cost savings compared to traditional retail pharmacies. We sought to understand the availability and cost of generic prescription drugs at five national DTC pharmacies.

METHODS

Definitions and Cohort Selection

Using the publicly available Medicare Part D drug spending dashboard, we identified generic drugs as those for which the brand name was the same as the active ingredient.²⁷ We excluded generics administered intravenously, those used by fewer than 50 Medicare recipients in 2020, and those with an outlier flag indicating potential data inaccuracies. From this sample, we identified the 100 most expensive generic prescription drugs based on the highest average Medicare Part D spending per beneficiary in 2020 (Supplement).²⁷ Separately, we identified the 50 most commonly used generic drugs based on the number of patients who filled a prescription for the drug in 2020. There was no overlap in drug formulations between these two groups (Supplement).

The Medicare Part D Dashboard combines spending across multiple formulations. When an expensive generic had multiple formulations (e.g., tablet, oral solution, suppository), we included all formulations except those that did not independently meet the definition for being among the 100 most expensive generic drugs after reviewing the Medicare Dashboard and Merative Micromedex (Supplement).^27,28 For common generic drugs with multiple formulations, we selected the most commonly prescribed formulation based on the authors’ clinical judgment. For two topical common generics (mupirocin and triamcinolone acetate), both cream and ointment formulations were included. For each generic drug formulation, we selected a standardized quantity (e.g., 30 tablets or capsules, 1 inhaler) to facilitate price comparison across DTC pharmacies and the most common maintenance dosage strength using UptoDate or when there was none, the lowest dosage strength.²⁹

Direct-to-Consumer Pharmacies

We identified five national DTC pharmacies that sell generic prescription drugs at publicly available prices without health insurance: Amazon, Costco, Health Warehouse, MCCPDC, and Walmart (Supplement Table 1).^{23,24,30–32} We excluded pharmacies limited to a particular clinical area of focus (e.g., men’s health) and those that required pharmacy-specific subscription fees;³³ Amazon and Costco have membership fees, but the pharmacy is just one of many benefits available to members. Walmart stores have a full-service pharmacy that accepts insurance, but we focused on the “$4 prescriptions,” a subset of generics sold directly to patients without insurance (Supplement Table 1).³²

Outcomes

During April and May 2023, we searched the websites of each DTC pharmacy to determine the availability and cost of each generic drug for a standardized strength and quantity (Supplement Tables 2 and 3). Drugs were counted as available if the pharmacy sold any dosage strength of a select generic drug formulation.

For drugs that were available at a DTC pharmacy, we extracted prices for a standard quantity (e.g., 30 tablets) of the smallest dosage strength. In many cases, this was equal to a 30-day supply, but in some cases, it was less than that. Prices were inclusive of fees and shipping for all pharmacies (Supplement Table 1). For the cost comparison analysis, we used the smallest strength of each dosage form. If this strength was unavailable, but a different strength of the same generic drug was available, then the drug formulation was marked as available but excluded from cost comparisons. If the alternative drug strength was available across all pharmacies selling the drug, then it was included in the cost analysis.

For comparison, we obtained retail pharmacy prices using GoodRx.³⁴ Retail drug prices can vary over time and by pharmacy type, but do not generally vary by geography for national pharmacy chains.^35,36 We searched retail prices in El Paso County (ZIP code 79901), which is in the 100th percentile by area deprivation index; prices were available for up to two national chain pharmacies (CVS and Walgreens) and three grocery-based pharmacies (Albertsons, HEB, and Kroger) in this ZIP code.^34,37,38

Because generic prices are typically lower for drugs with more competition, we identified the number of generic manufacturers supplying each expensive generic drug using the FDA’s National Drug Code directory based on the number of abbreviated new drug applications under which versions of the drug are sold.³⁹ We included authorized generics sold under the same new drug application as the brand-name version, but if multiple labelers marketed authorized generic versions, we treated them as a single manufacturer.^2,39

We classified each generic drug into one of nine therapeutic classes (antimicrobial, cancer, cardiovascular, gastrointestinal or metabolic, hematologic, immunomodulating, musculoskeletal, neurologic, or other) using the World Health Organization’s Anatomic Therapeutic Classification system.⁴⁰ This study was not submitted to the institutional review board because it used publicly available, non-identifiable data that does not constitute human participants’ research (45 CFR 46.102).

Statistical Analyses

We compared the availability of expensive versus common generic drug formulations at the five DTC pharmacies using chi-square tests. We calculated the difference in the mean number of DTC pharmacies that sell expensive versus common generics and the difference in the median number of manufacturers that produce these generics using Wilcoxon rank-sum tests. For each drug available at 1 or more DTC pharmacies, we calculated how frequently each pharmacy had the lowest out-of-pocket cost for patients. We also performed this analysis within each DTC pharmacy to determine how frequently the drugs that it sold were the lowest price among other DTC pharmacies included in the analysis. We calculated the median absolute and relative cost difference between the lowest DTC pharmacy drug cost and the lowest retail pharmacy cost. Analyses were performed using Stata 17.0; all tests were 2-tailed, and p-values were deemed significant at p < 0.05.⁴¹

RESULTS

We included 118 formulations for 100 expensive generic prescription drugs and 52 formulations for 50 common generic prescription drugs (Fig. 1; Supplement). The average spending per patient in Medicare Part D in 2020 on an expensive generic was $16,046 (standard deviation, $28,096). Among common generics, a median of 3,257,496 (IQR, 2,711,747 to 5,021,564) patients filled a prescription in 2020 (Supplement).

Figure 1.

Identification of expensive and common generic prescription drugs. The flow diagram summarizes how we identified expensive and common generic prescription drugs using the 2020 Medicare Part D Dashboard to evaluate the availability and cost of these generics at five national direct-to-consumer pharmacies. ^aIdentified using the highest average spending by patient in Medicare Part D plans in 2020. ^bIdentified based on drugs prescribed to the highest number of individuals. ^cAll eligible drug formulations were included. See Supplement for additional details. ^dThe most commonly prescribed formulation was selected based on the authors’ clinical judgment. For two topical common generics (mupirocin and triamcinolone acetate), both cream and ointment formulations were included. ^eSix drug formulations were excluded due to differences in the available quantity or dosage strength that prevented price comparisons between direct-to-consumer pharmacies. For example, sumatriptan-naproxen was available at 4 direct-to-consumer pharmacies, 3 of which sold 9 tablets and 1 sold 30 tablets, making the costs to patients incomparable.

Most drug formulations were oral tablets or capsules. The most common therapeutic drug classes included neurologic, antimicrobial, gastrointestinal or metabolic, and cardiovascular. On average, drugs in the common generic cohort had more manufacturers than those in the expensive generic cohort (median 9 (IQR, 6.75 to 14) vs. 4.0 (IQR, 2 to 7), p < 0.001, Table 1).

Table 1.

Characteristics of the Two Cohorts of Generic Prescription Drug Formulations

	Expensive genericsa (n = 118)	Common genericsb (n = 52)	p-value
Route of administration and dosage form, n (%)			0.014
Oral tablet	69 (58)	37 (71)
Oral capsule	23 (20)	7 (14)
Oral solution or suspension	10 (8)	-
Injectionc	9 (8)	-
Otherd	7 (6)	8 (15)
Number of manufacturers, mean (SD)e	5 (3.5)	9.9 (4.7)	< 0.001
Therapeutic class, n (%)f			0.007
Antimicrobial	16 (14)	7 (13)
Cancer	11 (9)	-
Cardiovascular	9 (8)	13 (25)
Gastrointestinal or metabolic	12 (10)	6 (12)
Hematologic	5 (4)	-
Immunomodulating	6 (5)	-
Musculoskeletal	7 (6)	-
Neurologic	33 (28)	9 (17)
Otherg	19 (16)	17 (33)

^aIdentified as the 100 most expensive generic drugs with the highest average Medicare Part D spending per beneficiary in 2020, excluding intravenous drugs and drugs administered to less than 50 Medicare recipients

^bIdentified as the 50 generic drugs in Medicare Part D in 2020 with the highest number of patients who filled a prescription for the drug

^cExpensive generics: includes subcutaneous (6) and intramuscular (3) solutions and suspensions

^dExpensive generics: intranasal (1), inhalation (1), ophthalmic (1), rectal (1), transdermal (3). Common generics: intranasal (1), inhalation (1), ophthalmic (1), transdermal (5)

^eBased on the number of unique abbreviated new drug applications obtained using the National Drug Code directory. In cases when multiple labelers had authorized generic versions (n = 8 for expensive generics), we combined them into a single competitor

^fDetermined using the World Health Organization Anatomical Therapeutic Chemical classification. Drugs were categorized as either cancer or immunomodulatory after a manual review using Lexicomp

^gExpensive generics: antiparasitic (3), dermatologic (4), genitourinary (2), respiratory (1), sensory (1), systemic hormonal preparation (4), other (4); common generics: dermatologic (4), genitourinary (1), hematologic (1), immunosuppressant (1), musculoskeletal (4), respiratory (3), sensory (1), systemic hormonal preparation (2)

Availability at DTC Pharmacies

Overall, 94 of the 118 expensive generics (80%) and 51 of the 52 common generics (98%) were available at 1 or more of the DTC pharmacies (p < 0.001). Among the 118 expensive generic drug formulations, Amazon sold 85 (72%), Costco 38 (32%), Health Warehouse 73 (62%), and MCCPDC 31 (26%); none were available on the Walmart $4 list. Of the 52 common generic drug formulations, Amazon sold 50 (96%), Costco 51 (98%), Health Warehouse 50 (96%), MCCPDC 45 (87%), and Walmart 18 (35%) (Fig. 2).

Figure 2.

Availability of expensive and common generics at direct-to-consumer pharmacies. The sample includes 118 expensive generic formulations and 52 common generic formulations. Twenty-four expensive generic drug formulations (20%) were unavailable at all five direct-to-consumer pharmacies in the sample. Only one common generic drug (oxycodone/acetaminophen, 5 mg/325 mg) (2%) was unavailable at all pharmacies. Abbreviations: Health WH, Health Warehouse; MCCPDC, Mark Cuban Cost Plus Drug Company. * P < 0.05 for chi-square test.

Expensive generics were available at an average of 1.9 of the 5 pharmacies (95% CI 1.7–2.1), compared with 4.1 for common generics (95% CI, 3.8–4.4, p < 0.001) (Supplement Table 4).

Cost of Drugs at DTC Pharmacies

Among the 94 expensive generic formulations sold at one or more DTC pharmacies, 6 were excluded from the cost analysis due to differences in the available quantity or dosage strength that prevented price comparisons between pharmacies (e.g., 9 vs. 30 tablets of sumatriptan-naproxen). Of the remaining 88 expensive generic drugs, Amazon was the lowest cost for 42 (47%), Costco for 11 (13%), Health Warehouse for 13 (14%), and MCCPDC for 23 (26%) (Fig. 3). Among the 51 common generics sold at 1 or more DTC pharmacies, Costco was the lowest cost for 16 (31%) drugs, followed by Amazon for 14 (27%), Walmart for 10 (20%), Health Warehouse for 6 (12%), and MCCPDC for 5 (10%) drugs (Fig. 3).

Figure 3.

Lowest cost pharmacy for generic drugs available for sale at one or more pharmacies. This figure includes 88 expensive drug formulations and 51 common generic formulations that were available for sale by at least one direct-to-consumer pharmacy. Six expensive drug formulations were excluded due to differences in the available quantity or dosage strength that prevented price comparisons between pharmacies. Among the remaining 112 expensive drug formulations, 24 (21%) formulations were unavailable at any pharmacy. Of the 52 generic drug formulations, one common generic drug (oxycodone/acetaminophen, 5 mg/325 mg) was unavailable at any pharmacy. Shipping costs were included in the cost for all five direct-to-consumer pharmacies.

Of the available expensive generic formulations at each DTC pharmacy, there was variation in how often each pharmacy offered the lowest cost for patients. For example, Health Warehouse carried 67 expensive generic drug formulations, but it was the least expensive option for 13 (19%), while MCCPDC was the least expensive option for 23 of the 27 available generic formulations (85%; Fig. 4). Among common generic formulations sold at each DTC pharmacy, Costco had the lowest cost for patients 31% of the time, more than any DTC pharmacy.

Figure 4.

Frequency of lowest cost generics available by pharmacy. Of the 118 expensive generic drug formulations, 24 (20%) were unavailable at any direct-to-consumer pharmacy. Of the 94 expensive generic drug formulations sold, 79 (84%) were sold at Amazon, 38 (40%) at Costco, 66 (70%) at Health Warehouse (Health WH), 27 (29%) at Mark Cuban Cost Plus Drug Company (MCCPDC), and none at Walmart. Of the 52 common generic drug formulations, 1 (2%) was unavailable at any direct-to-consumer pharmacy. Of the 51 common generic drug formulations sold, 50 (98%) were sold at Amazon, 51 (100%) at Costco, 50 (98%) at Health WH, 45 (88%) at MCCPDC, and 18 (35%) at Walmart.

DTC Pharmacy Costs Compared to Retail Pharmacy Costs

Seventy-seven of the 88 (88%) available expensive generic formulations had retail prices available from GoodRx (Fig. 1). Among these, the lowest DTC pharmacy cost was a median 76% (IQR, 53–91%) less than the least expensive retail pharmacy price, which translated to a median absolute potential savings of $231 (IQR, $129–$792) per standardized quantity and strength (usually 30 tablets or capsules). Among the 51 common generic drugs with available retail prices, the lowest DTC pharmacy cost was a median 75% (IQR, 67–83%) lower than the retail price, which translated to an absolute median savings of $19 (95% CI, $10–$34). Representative examples of expensive and common generic medicines from each DTC pharmacy, with cost savings, are presented in Table 2.

Table 2.

Direct-To-Consumer and Retail Pharmacy Prices for Two Cohorts of Generic Drugs

Drug	Medical condition(s)a	Quantity	Lowest DTC pharmacy cost, USD	Lowest retail cost, USD	Cost difference, USD (%)
Expensive generics
Lamotrigine      25 mg      Oral disintegrating tablet	Bipolar disorder, seizures	30	63 (Amazon)	227 (CVS)	164 (−72%)
Glatiramer     40 mg/ml (1 ml)     Subcutaneous	Multiple sclerosis	12 Pre-filled syringes	1259 (Amazon)	5220 (Albertsons)	3961 (−76%)
Niacin     500 mg     Oral tablet, extended release	Elevated triglycerides	30	27 (Costco)	416 (CVS)	389 (−93%)
Lamivudine/zidovudine     150 mg/300 mg     Oral tablet	HIV infection	30	26 (Health Warehouse)	734 (Albertsons)	708 (−96%)
Abiraterone     250 mg     Oral tablet	Prostate cancer	30	42 (MCCPDC)	2987 (Walgreens)	2945 (−99%)
Common generics
Diclofenac     1% (100g tube)     Transdermal gel	Osteoarthritis Musculoskeletal pain	1 Tube	13 (Amazon)	40 (Walgreens)	27 (−68%)
Pantoprazole     20 mg     Oral tablet	Acid reflux	30	9.2 (MCCPDC)	44 (Albertsons)	35 (−79%)
Rosuvastatin     5 mg     Oral tablet	High cholesterol	30	7.50 (Health Warehouse)	110 (Walgreens)	103 (−93%)
Metoprolol     25 mg     Oral tablet	Heart failure; hypertension Myocardial infarction	60	4 (Walmart)	16 (Albertsons)	12 (−75%)
Azithromycin     250 mg     Oral tablet	Bacterial infections	6	7.8 (Costco)	35 (Albertsons)	27 (−78%)

Sample of expensive and common generic prescription drugs selected to illustrate differences in the cost of these medications to patients. Retail prices were obtained using GoodRx in the standardized 79901 ZIP code. This analysis was completed for 77 of 95 available expensive drug formulations and all 51 available common generic drug formulations

Abbreviations: MCCPDC Mark Cuban Cost Plus Drug Company, HIV human immunodeficiency virus

^aCommon FDA-approved indications for which the expensive and common generic drugs are used

DISCUSSION

In this cross-sectional study of five national direct-to-consumer pharmacies, we found substantial variation in the availability and cost of generic drugs. Although nearly all commonly used generics were available at 1 or more of these pharmacies, 20% of the most expensive generics were unavailable at any of the 5 pharmacies. Even when generics were available in these pharmacies, the lowest-cost pharmacy varied by drug. The lowest available price at DTC pharmacies averaged 75% lower than the lowest retail pharmacy price, which translated to much higher estimated absolute savings for expensive versus common generics among patients responsible for the full retail price.

DTC pharmacies provide an alternative, lower-cost option for acquiring generic prescription drugs for the nearly 1 in 3 patients who struggle to afford medicines.^14,15,17,42 Previous studies have shown substantial savings over the prices paid by Medicare Part D plans for patients using DTC pharmacies, including Costco and MCCPDC, for select generics.^19,22,43,44 Because most insured patients have minimal out-of-pocket costs for generic drugs, lower DTC prices may not offer savings to many insured patients. For example, the Costco study found that Costco prices were only lower than out-of-pocket costs paid by Medicare Part D recipients for 11% of generic prescription fills.¹⁹ However, uninsured patients and many with insurance continue to pay the full retail price for generic drugs. In 2022, 30% of working adults were enrolled in a high-deductible health plan with an annual deductible over $1000 for individuals and $2000 for families.⁴⁵

Our data highlight some important limitations of DTC pharmacies that merit consideration by patients, prescribers, and policymakers. For the most expensive generics that are likely to cause affordability challenges for patients, many were unavailable at some of the DTC pharmacies. And even when generics were available at 1 or more DTC pharmacies, the lowest cost option varied widely by drug. This variation in the availability and cost of generics at DTC pharmacies requires patients and prescribers to shop around to find the best deal, which is a time-consuming process with financial tradeoffs.^20,46 To our knowledge, there are no simple, accurate, and comprehensive tools to help patients identify the lowest-cost generic drug across all retail, community, and DTC pharmacies in real time. Such a tool could greatly assist patients and clinicians. However, many patients with chronic conditions like hypertension, diabetes, and heart failure take multi-drug regimens; expecting patients to shop around and purchase each of their drugs at a different pharmacy is complex and unrealistic. Most clinicians do not know the costs of the prescription drugs they prescribe and only a minority are able to have cost conversations at the time of prescribing.^47,48

A more sustainable solution would be more transparent and less variable prices at traditional retail pharmacies that accept insurance. Several large companies have announced such changes, perhaps in response to competition by DTC pharmacies. Optum, one of the largest pharmacy benefit managers, recently announced that it would match the lowest generic prices for the drugs it covers, including prices at DTC pharmacies, although the details of how this will function are unclear.⁴⁹ In 2023, CVS Health and Cigna’s Express Scripts both announced plans for pharmacy reimbursement to be based on drug ingredient costs plus a markup, similar to the MCCPDC pricing model, although the specific details have yet to be announced.^50–52

Another solution is ensuring that patients and prescribers have accurate real-time cost estimates for prescribed medications. Real-time prescription benefit tools integrated into electronic health records are increasingly available, but these tools are imperfect and do not include information about direct-to-consumer pharmacies.^53–55 Ensuring that these real-time benefit tools include comparative costs at DTC pharmacies would help make the tools more practical for patients and clinicians, allowing patients to choose the lowest cost pharmacy at the time a medication is prescribed.

Our study has limitations. First, this is a cross-sectional study; the availability of generic drugs at DTC pharmacies and prices at these pharmacies and traditional retail pharmacies may change or increase over time. We compared DTC pharmacy prices to retail prices from a single ZIP code, although prices at large chain retail pharmacies like CVS and Walgreens tend not to vary by geography.^35,36 Our retail cost analysis was also limited to 5 pharmacies with available data (CVS, Walgreens, Albertson, HEB, Kroger), and prices for individual patients may vary depending on which pharmacies are available at their location. Second, 12% of available expensive generics (11/88) lacked retail pharmacy prices from GoodRx and were excluded from the cost analysis. Third, we did not account for the cost of membership to Costco or Amazon Prime in our analysis. For some patients, this membership cost could pose an additional barrier to accessing the DTC pharmacy, although Amazon Prime has approximately 160 million American subscribers while Costco has an estimated 85 million members in the USA.^56,57 Fourth, the dataset (Medicare Part D Dashboard) we used to identify expensive and common generic drugs is based on data from 2020, and the distribution of which generics are most expensive or highly used could have changed over the subsequent 3 years. Fifth, estimated cost savings may underestimate the savings for a monthly supply, both because of the drug strength we selected and because a standard supply (e.g., 30 tablets) may not last a full 30 days. Patients taking higher strengths of a generic drug would have greater savings using DTC pharmacies compared to retail pharmacy price.

Differences in the availability and costs of generic prescription drugs sold by direct-to-consumer pharmacies provide a glimpse into the challenges patients may face trying to find inexpensive options for their essential medicines. Physicians can use this information to help guide patients trying to access generic drugs at affordable prices, and policymakers can use this information to guide more rational policies to ensure that all patients are able to access generic drugs at low prices.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

Arnold Ventures. Dr. Rome and Dr. Kesselheim’s work is also funded by grants from the Commonwealth Fund, Elevance Health Public Policy Institute, and the National Academy for State Health Policy.

Data Availability

All data generated or analyzed during this study are included in this published article and its supplementary files.

Declarations:

Conflict of Interest:

Outside of the submitted work, Dr. Kesselheim reports serving as an expert witness in a case on behalf of a group of state attorneys general and private insurance carriers relating to generic drug pricing.

Disclaimer

The funder had no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.