Finding the Lowest-Cost Pharmacy for Cancer Supportive Care Medications: Not So Easy

PURPOSE:

To decrease the financial burden on people with cancer, clinicians and patients increasingly use medication price comparison websites to seek pharmacies where medications may be cheaper. Shopping around at different pharmacies can add additional time and logistic burden to patients and care partners. We sought to determine whether a single pharmacy consistently offered the lowest price for symptom control medications.

METHODS:

We compiled medications/formulations used to manage two common cancer-associated symptoms: nausea/vomiting and anorexia/cachexia. We extracted discounted, lowest price with coupon prices for a typical fill of these medications at nine pharmacies in Minneapolis, MN, using GoodRx. We compared prices across formulations and pharmacies to assess whether a pharmacy consistently offered the lowest price.

RESULTS:

We included 24 formulations for nausea/vomiting (14 generic and 10 brand-name) and 19 for anorexia/cachexia (12 generic and seven brand-name). Prices for brand-name formulations were similar across pharmacies, but prices of generic formulations varied widely across pharmacies. For example, the prices of a seven-unit fill of generic 5-mg olanzapine tablets ranged from $4 to $57 US dollars. No single pharmacy consistently offered the lowest price across the formulations studied. For example, for the 12 generic formulations for anorexia/cachexia, one pharmacy had the highest price for four formulations and the lowest price for two others.

CONCLUSION:

In this study of discounted medication prices, we found that no single pharmacy in an urban zip code consistently offered the lowest price for medications used to manage two common cancer-associated symptoms. Well-intentioned efforts to pursue the cheapest source of each medication by visiting multiple pharmacies may add extra time and logistic toxicity to patients and care partners. This approach can increase redundant scripts and expose patients to medication-related adverse events.

INTRODUCTION

People with cancer face significant economic and time burdens associated with cancer-directed treatment and supportive care.^1-3 Recently, the costs of symptom control medications have received attention as an important source of financial toxicity for people with cancer.^4,5 These costs have traditionally been under-recognized since symptom control medications are often over-the-counter or lower-cost generic formulations.⁴ People with cancer face long and intense treatment regimens, requiring several supportive care medications, some of which are used inappropriately.⁶ Newer supportive care medications are costly.⁷ Clinicians and the general public are now more aware of costs of medications and the variability in costs of the same medication between different pharmacies.^8,9

Even small co-pays can lead patients to abandon prescriptions. A study of more than 38,000 insured patients with cancer found that a co-pay of < $10 US dollars (USD) was associated with a 10% rate of prescription abandonment.¹⁰ In an effort to decrease the financial burden faced by people with cancer, particularly those who are underinsured or uninsured, some clinicians are using (and encouraging their patients to use) online prescription medication price aggregator websites, such as GoodRx.¹¹ These can help direct patients to pharmacies where supportive care medications are cheaper. As an example, prices for a single fill of 4-mg ondansetron tablets (30 units) can vary 8× between pharmacies within the same zip code.^4,12 Although directing patients to the cheapest pharmacy for a medication could reduce patient costs and enable patients to access treatments in theory, people with cancer typically need to manage multiple medications. As an example, a patient initiating folinic acid, fluorouracil, irinotecan, oxaliplatin chemotherapy for advanced pancreatic cancer will receive new prescriptions for at least two different antiemetics (eg, ondansetron and prochloperazine) and at least one antidiarrheal (eg, loperamide) for as-needed use at home, in addition to medications used to manage pain and other cancer-related symptoms, and other non–cancer-related medications.^5,12,13

If a single pharmacy routinely or predominantly offers the lowest prices of commonly used medications, clinicians and patients could preferentially use that pharmacy for most/all medications. However, if different pharmacies offer the lowest price for different prescriptions, patients would need to shop around to avail the lowest cost of each medication. This may be excessively burdensome.

Thus, using the examples of medications used for nausea/vomiting and anorexia/cachexia, we sought to determine whether a particular pharmacy consistently offered the lowest cost for medications used to manage cancer-associated symptoms. This information can highlight the challenges patients may face in lowering their costs of treatment.

METHODS

We conducted a cross-sectional, descriptive study. We first compiled a list of medications used to manage two cancer-associated symptoms—nausea/vomiting and anorexia/cachexia. We selected these symptoms because (1) they are pervasive and physically and emotionally distressing, (2) several medication options are available and routinely used to manage them, and (3) they cover both US Food and Drug Administration–approved (nausea/vomiting) and off-label (anorexia/cachexia) use of medications. We compiled medications using clinical guidelines, UpToDate, Inc, and authors' experience.^4,12,14 We compiled all formulations of a medication (eg, tablet, capsule, and solution) commonly used in clinical practice and separately considered brand-name and generic versions of each product. None of the medications included in this study were available for over-the-counter purchase without a prescription. Diphenhydramine, for example, can sometimes be cheaper to buy over the counter without a prescription, than with a prescription, and thus was not included. Using the most commonly filled dose (strength) of each medication and the typical duration of medication use for a particular symptom on the basis of clinical guidelines and clinical judgment, we calculated a typical quantity (fill) for each medication. We included 24 medications/formulations (hereafter referred to as medications) for nausea/vomiting (14 generic and 10 brand-name) and 19 for anorexia/cachexia (12 generic and seven brand-name). A full list of medications and formulations are available in the Data Supplement (online only).

We used the GoodRx website, a nationally available medication price comparison tool that provides real-time information on medication prices available to consumers at participating pharmacies in (or near) their zip code.¹⁵ For each medication and fill amount, GoodRx reports an undiscounted, average retail price, and a discounted lowest price with coupon at individual pharmacies. We compared the discounted lowest price with coupon for each medication (including brand-name v generic) at individual pharmacies as the primary analysis variable. We confirmed the prices reported online with a telephone call to three individual pharmacies for three different medications. We extracted data on a single day in October 2021.

We selected the geographic area as Minneapolis, MN (zip code 55455). It is an urban area with low median income and high population density. We conducted a similar analysis in Saint Cloud, MN (zip code 56301), which is a smaller city 60 miles northwest of Minneapolis. This is sufficient distance to ensure that the GoodRx geographic regions do not overlap. In sensitivity analyses, we found minimal difference in patterns across pharmacies in the two regions. In this study, we present data from one geographical area/zip code (Minneapolis). Prior studies have grouped pharmacies by type/size (eg, large chain, small chain, and independent).^16,17 Although this is intuitive, this approach can mask variation within groups. The focus of the current project is the patient experience and whether there is a single specific pharmacy a patient can use to get the lowest price on many of their medications. Thus, we compared prices across nine individual pharmacies for which GoodRx discounts were available near our chosen zip code, representing both large and small chain pharmacies and independent pharmacies (Walgreens, CVS, Walmart, Target, Costco, Hy-Vee, Kroger, Thrifty White, and Community).

Using Google Maps, we extracted driving time from the University of Minnesota Medical School (420 Delaware Street SE, Minneapolis, MN 55455) to five pharmacies (the nearest Walgreens, Costco, Hy-Vee, Thrifty White, and Community pharmacy) and then back to the medical school. We assumed minimal traffic and no wait times at the pharmacies.

We present descriptive results. Because we used publicly available data, and this was not human subjects research, in accordance with 45 CFR §46.102(f), we did not submit this study to an institutional review board or require informed consent procedures. We used Microsoft Excel v16.0 (Redmond, WA) and GraphPad Prism v7.0 (San Diego, CA) for analyses.

RESULTS

For brand-name medications, for both nausea/vomiting and anorexia/cachexia, prices did not vary significantly between pharmacies (Data Supplement). For generic medications, prices varied considerably across pharmacies (Fig 1). For example, a seven-unit fill of 1-mg generic granisetron tablets cost approximately $20 (USD) at Kroger, Hy-Vee, and Thrifty White, but over $100 (USD) each at CVS and Target. A seven-unit fill of generic 5-mg olanzapine tablets cost approximately $4 (USD) at Kroger and $57 (USD) at Walmart, an almost 15-fold difference. There was considerable variation in the range of price differences at different pharmacies (most expensive pharmacy minus least expensive pharmacy) across medications. For some medications (eg, a 60 count of 5-mg metoclopramide tablets), the price difference (most expensive minus least expensive pharmacy) was $5 (USD). For others (eg, a 60 count of 5-mg metoclopramide oral dissolving tablets), the price difference was > $200 (USD).

FIG 1.

GoodRx discount prices for generic formulations of medications used to manage anorexia/cachexia and nausea/vomiting (each dot represents discounted price at a pharmacy, and # denotes fill count). USD, US dollars.

Given the variation in prices for generic medications across pharmacies, we explored whether any of the nine pharmacies consistently provided the lowest discounted price (Fig 2). For the 14 generic antiemetics, Kroger had the cheapest price for seven; Thrifty White and Hy-Vee each had four; and Costco, Walgreens, and Community each had two. For the 12 generic medications used for anorexia/cachexia, Thrifty White and Kroger each had the cheapest price for three, and Costco, Hy-Vee, Walgreens, and Community each had two (more than one pharmacy can share the lowest or highest price). The Data Supplement presents summaries of costs of generic medications. For each pharmacy, we included the number of times the pharmacy had the maximum or minimum price for a given medication, the number of times the pharmacy's price for a given medication was greater than or less than or equal to the median, and the number of times the pharmacy's price falls within the interquartile range.

FIG 2.

Pharmacies with the highest and lowest GoodRx discount prices—generic formulations of medications used to manage anorexia/cachexia and nausea/vomiting (teal: lowest price for that formulation; red: highest price for that formulation. More than one pharmacy may be teal or red for one formulation since lowest/highest prices may be shared by more than one pharmacy; # denotes fill count.).

Figure 3 presents a map depicting the path of a hypothetical trip to five pharmacies, each of which is the cheapest option for a particular medication (Data Supplement). These medications (eg, dexamethasone, dronabinol, olanzapine, ondansetron, and prochlorperazine) are often used together for a person receiving chemotherapy and experiencing symptoms (eg, nausea and anorexia). The closest pharmacy to the University of Minnesota Medical School is a 12-minute drive roundtrip. Using GoodRx discount prices, a patient picking up all five medications at this closest pharmacy would pay $96 (USD) out-of-pocket. If a patient chose to shop around for the cheapest pharmacy for each of the five medications, the patient's out-of-pocket cost would decrease by $19 to be $77 (USD). The best-case driving time for this trip would be 63 minutes.

FIG 3.

Map demonstrating a best-case scenario (of travel distance and time) of a hypothetical trip to five pharmacies and back to the starting point. A, B, C, D, E represent the 5 pharmacies.

DISCUSSION

In this cross-sectional study comparing out-of-pocket costs for symptom control medications across pharmacies in a single zip code, we found that (1) the prices for generic formulations varied considerably across pharmacies and (2) no single pharmacy was consistently the cheapest across the medications studied. Although using medication price comparison websites can reduce out-of-pocket costs for patients, pursuing the lowest cost of each medication can add significant logistic and time burden to patients and their care partners.^3,18 Given the price variation across pharmacies and the lack of a clear cheapest pharmacy, the burden of always chasing the lowest price may outweigh the savings in out-of-pocket costs.

Increasingly, clinicians and patients are aware of and are using medication price comparison websites, such as GoodRx, to find the lowest cost option for medication(s).^8,9 This is highlighted by growing research in this area, as well as testimonials on social media about how to reduce costs by exploring GoodRx and/or using a specific pharmacy.^16,17,19,20 Although we broadly support patients having access to affordable medications and have ourselves used GoodRx as clinicians and patients, this research initiative was borne from our clinical experience of patients and care partners mentioning the time and logistic toxicity of pursuing the lowest cost for multiple medications. We do not find a single pharmacy that is consistently the cheapest for commonly used symptom control medications. People with cancer receive multiple symptom control medications, and well-intentioned efforts to decrease costs by pursuing the lowest-cost source of medications may add unnecessary burden. Our findings also suggest against clinicians blindly directing all patients to a specific pharmacy by following a rule of thumb that a particular pharmacy (eg, Costco) is usually the cheapest. There is no guarantee that this strategy will result in savings for a given patient and could impose significant burden for a patient who does not live close to such a pharmacy.

The hypothetical shopping trip in our analysis highlights the trade-off patients have to consider when trying to shop around for the cheapest price. A patient living at the University of Minnesota Medical School could save $19 (USD) by traveling to five pharmacies versus simply going to the closest pharmacy. But, the burden of this cost saving is at least an extra hour of just driving (best possible route, not accounting for traffic, parking, wait times at the pharmacy, etc). Although the price difference between the closest pharmacy and the cheapest pharmacies was relatively modest in this hypothetical scenario ($19 [USD]), patients may face difficult choices when differences are hundreds of dollars, which is often the case. It is also important to note that the burden of seeking cheaper medications is often shared by a caregiver. These burdens will be exacerbated for people and communities facing social barriers to health (low health literacy and low technology access) or in areas with a lower density of pharmacies (pharmacy deserts). People with cancer already spend a significant portion of their time pursuing cancer-related care.^1,3,21-23 Adding to confusion and logistic burdens, for a pharmacy that appears on the GoodRx page for zip code 55455, the closest physical pharmacy is almost 400 miles away in Sterling, IL.

There are other broader issues with pursuing medications at multiple pharmacies or rather with any cash-pay prescription. First, filling multiple medications at different pharmacies can circumvent safety checks such as screening for drug-drug interactions and expose patients to multiple, redundant, potentially overlapping prescriptions, contributing to polypharmacy.²⁴ Patients with cancer filling prescriptions at external pharmacies are less satisfied than patients working with a local pharmacist-led program, likely because of fragmented care.²⁵ Second, medication prices are dynamic, and the lowest-priced pharmacy for a medication may change without patients or care teams being aware, as contracts change. For medications that require refills, unless a person or process is rechecking prices across pharmacies before each fill, there is no guarantee that the patient is getting the lowest price possible in subsequent fills by continuing to refill at the original pharmacy. Third, even if the discounted price at a pharmacy is not the lowest discounted price across multiple pharmacies, the discounted price is likely to be much lower than a nondiscounted price. Finally, for patients with prescription medication coverage, the price paid at a pharmacy (for either the undiscounted cash price or the discounted price with coupon) does not count toward the deductible. Discounted medications may thus help cut costs for people who are taking a few, inexpensive medications (who would never meet their deductible anyway) or people without prescription medication coverage. Many people with cancer receive costly cancer-directed treatments and other supportive care or symptom control medications and would meet their deductible if they obtain medications through their prescription medication coverage.

This work has several limitations. First, we focus on medications used to manage two common cancer-associated symptoms. Given prior work demonstrating price variability across pharmacies, we believe our findings apply to the full range of prescription medications they are on.^16,17 Second, we explored prices in the greater Minneapolis area. Minneapolis is a large city (population, approximately 400,000) with multiple pharmacy options; smaller cities and rural areas may have fewer choices. Although we found similar price patterns in Saint Cloud across pharmacies, driving distances and associated toxicity will be higher. Third, this was a cross-sectional analysis. Medication prices are dynamic, and the full implications of medication price variability are not fully described here. Fourth, GoodRx coupon prices cannot be combined with prescription medication coverage. These data are more applicable to underinsured or uninsured people. In 2018, almost half of adults younger than 65 years had inadequate insurance (22.6% underinsured, 10.0% coverage gap, and 12.4% uninsured). Additionally, even those with coverage may have limited prescription medication coverage.²⁶ These data may also apply to some patients opting not to use their insurance such as when their co-pay is greater than the discounted price offered with coupons. Finally, the primary data end point for this study was the discounted, lowest price with coupon. Other work on GoodRx prices has focused on the undiscounted average retail price.^16,17 Although complex and opaque rebates between pharmacy benefit managers and pharmacies affect the discount prices, given the patient-centered focus and patient point of view of this work, we believe discount prices are more appropriate.

In conclusion, spending on symptom control medication causes significant financial burden for patients with cancer, who often take multiple medications simultaneously. Online, medication price comparison websites that provide real-time data and discounted prices are emerging as important tools for people trying to manage their out-of-pocket medication costs. We show that prices of generic medications vary significantly across pharmacies, and no pharmacy in a single zip code consistently offers the lowest price across multiple medications. Shopping around for cheaper medications at multiple pharmacies can add significant time and logistic toxicity to patients and their care partners and increases risk of drug-drug interactions. This work cautions against blindly adopting well-intentioned efforts to decrease costs for patients and emphasizes the need for patient access to safe and affordable medications.

AUTHOR CONTRIBUTIONS

Conception and design: Andrew Etteldorf, Ramy Sedhom, Beth Virnig, Arjun Gupta

Financial support: Arjun Gupta

Administrative support: Arjun Gupta

Collection and assembly of data: Andrew Etteldorf, Ramy Sedhom, Arjun Gupta

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Finding the Lowest-Cost Pharmacy for Cancer Supportive Care Medications: Not So Easy

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