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Figure 1.
Mean Prices of Brand-Name Drugs by Therapeutic Category
Mean Prices of Brand-Name Drugs by Therapeutic Category

The mean price across the 4 surveyed national pharmacy chains (Costco, CVS, Sam’s Club, and Walgreens) of brand name drugs in each therapeutic category for survey years 2009, 2011, 2014, and 2015. The graph demonstrates the relative magnitude of increase for each therapeutic category.

Figure 2.
Mean Prices of Acne and Rosacea Drugs
Mean Prices of Acne and Rosacea Drugs

The mean price across the 4 surveyed national pharmacy chains (Costco, CVS, Sam’s Club, and Walgreens) of Benzaclin, Finacea, Oracea, Retin-A Micro, 0.1%, and Tazorac cream, 0.1%, in 2009, 2011, 2014, and 2015. The prices of these drugs more than doubled; the price of Retin-A Micro more than quadrupled between 2009 and 2015.

Figure 3.
Mean Prices of Psoriasis Drugs
Mean Prices of Psoriasis Drugs

The mean price across the 4 surveyed national pharmacy chains (Costco, CVS, Sam’s Club, and Walgreens) of Oxsoralen-Ultra, Taclonex, and Soriatane in 2009, 2011, 2014, and 2015. The prices of these drugs increased substantially during this time frame; the price of Oxsoralen-Ultra more than quadrupled between 2009 and 2015.

Figure 4.
Mean Prices of Generic Drugs
Mean Prices of Generic Drugs

The mean prices across the 4 surveyed national pharmacy chains (Costco, CVS, Sam’s Club, and Walgreens) of generic drugs in survey years 2011 and 2014. The prices of some of these drugs remained relatively unchanged during this time frame, while the prices of others increased substantially; the price of nystatin-triamcinolone (Mycolog-II cream) increased 10-fold. The nonproprietary names for the remaining generic drugs are as follows: for Aclovate, alclometasone; Lidex cream, fluocinonide; Locoid cream, hydrocortisone butyrate; Lotrisone cream, clotrimazole-betamethasone; Retin-A cream, tretinoin; and Topicort cream, desoximetasone.

Table.  
Prices of Surveyed Prescription Drugs
Prices of Surveyed Prescription Drugs
1.
Gagnon  M-A, Wolfe  S. Mirror, mirror on the wall: Medicare Part D pays needlessly high brand-name drug prices compared with other OECD countries and with US government programs.http://carleton.ca/sppa/wp-content/uploads/Mirror-Mirror-Medicare-Part-D-Released.pdf. Published July 23, 2015. Accessed August 19, 2015.
2.
Collins  SR, Rasmussen  PW, Doty  MM, Beutel  S. The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014.http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2015/jan/1800_collins_biennial_survey_brief.pdf?la=en. Published January 2015. Accessed August 19, 2015.
3.
Mailankody  S, Prasad  V.  Five years of cancer drug approvals: innovation, efficacy, and costs. JAMA Oncol. 2015;1(4):539-540.PubMedArticle
4.
US Senate. Ranking member Cummings and Chairman Sanders investigate staggering price increases for generic drugs.http://www.sanders.senate.gov/download/face-sheet-on-generic-drug-price-increases. Published 2014. Accessed April 1, 2015.
5.
Alpern  JD, Stauffer  WM, Kesselheim  AS.  High-cost generic drugs—implications for patients and policymakers. N Engl J Med. 2014;371(20):1859-1862.PubMedArticle
6.
Payette  M, Grant-Kels  JM.  Generic drugs in dermatology: part II. J Am Acad Dermatol. 2012;66(3):353.e1-353.e15.PubMedArticle
7.
Bureau of Labor Statistics, US Dept of Labor. CPI inflation calculator.http://www.bls.gov/data/inflation_calculator.htm. Published 2015. Accessed August 19, 2015.
8.
Centers for Medicare & Medicaid Services. National health expenditures 2013 highlights.https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Published 2014. Accessed April 1, 2015.
9.
Gencarelli  DM.  Average Wholesale Price for prescription drugs: is there a more appropriate pricing mechanism? NHPF Issue Brief. 2002;(775):1-19.PubMed
10.
Greene  W. The emergence of India's pharmaceutical industry and implications for the US generic drug market. Washington, DC: US International Trade Commission, Office of Economics. Publication 2007-05-A. http://www.usitc.gov/publications/332/EC200705A.pdf. Published May 2007. Accessed August 19, 2015.
11.
Gilead Sciences. Hepatitis B and C treatment expansion.http://www.gilead.com/~/media/files/pdfs/other/hepatitis%20b%20and%20c%20treatment%20expansion%20-%20february%202015.pdf. Published February 2015. Accessed August 19, 2015.
12.
Mosendz  P. $1,000-a-day hepatitis C miracle drug gets a major price cut, just not in the US.The Wire. http://www.thewire.com/global/2014/04/1000-a-day-hepatitis-c-miracle-drug-gets-a-major-price-cut-just-not-in-the-us/360505/. Published April 11, 2014. Accessed August 19, 2015.
13.
US Government Accountability Office. Brand-name prescription drug pricing: lack of therapeutically equivalent drugs and limited competition may contribute to extraordinary price increases. Publication GAO-10-201. http://www.gao.gov/new.items/d10201.pdf. Published December 2009. Accessed August 19, 2015.
14.
Pollack  A. Patent for Amgen drug may undercut health care plan. New York Times. November 23, 2011:B7.
15.
Valeant Pharmaceuticals International Inc. Valeant pharmaceuticals resumes shipment of Oxsoralen-Ultra: Valeant investor relations. http://www.prnewswire.com/news-releases/valeant-pharmaceuticals-resumes-shipment-of-oxsoralen-ultrar-96966464.html. Accessed February 8, 2016.
16.
Centers for Disease Control and Prevention. Doxycycline shortage.http://www.cdc.gov/std/treatment/doxycyclineShortage.htm. Accessed April 1, 2015.
17.
US Food and Drug Administration, US Dept of Health and Human Services. FDA drug shortages: current and resolved drug shortages and discontinuations reported to FDA.http://www.accessdata.fda.gov/scripts/drugshortages/. Revised 2015. Accessed April 1, 2015.
18.
Dicken  JE. Prescription Drugs: an Overview of Approaches to Negotiate Drug Prices Used by Other Countries and US Private Payers and Federal Programs. Washington, DC: US Government Accountability Office; January 11, 2007. Publication GAO-07-358T.
19.
Department of Health and Human Services, Office of the Inspector General. Manufacturer safeguards may not prevent copayment coupon use for Part D drugs. Publication OEI-05-12-00540. http://oig.hhs.gov/oei/reports/oei-05-12-00540.pdf. Published September 2014. Accessed August 19, 2015.
Original Investigation
February 2016

Changes in Retail Prices of Prescription Dermatologic Drugs From 2009 to 2015

Author Affiliations
  • 1The Perelman School of Medicine at The University of Pennsylvania, Philadelphia
  • 2Department of Dermatology, The Miller School of Medicine at the University of Miami, Miami, Florida
JAMA Dermatol. 2016;152(2):158-163. doi:10.1001/jamadermatol.2015.3897
Abstract

Importance  Physicians from many specialties as well as primary care prescribe dermatologic medications; as insurance formularies become increasingly restrictive and more patients are covered with high-deductible insurance plans, many patients are forced to pay high retail prices to obtain their medications.

Objectives  To determine the changes in the prices of commonly prescribed dermatologic medications since 2009 and to identify trends in price increases for different classes of drugs.

Design, Setting, and Participants  Four national chain pharmacies received surveys requesting price data on commonly prescribed dermatologic drugs in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs. Subsequent surveys increased to eventually include 120 additional brand-name drugs and their generic alternatives when available. Owing to the frequency of prescription, diseases treated, or unusual price increases, 19 brand-name drugs surveyed in all 4 years were selected for final price trend analysis, which was conducted from August 1 to 15, 2015.

Main Outcomes and Measures  Retail prices of topical and systemic drugs for the treatment of various dermatologic conditions.

Results  Prices of surveyed brand-name drugs increased rapidly between 2009 and 2015. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled during the study period. Among these 19 drugs, the mean price increase was 401% during the 6-year survey period, with the majority of the price increases occurring after 2011. Prices of topical antineoplastic drugs had the greatest mean absolute and percentage increase ($10 926.58 [1240%]). Prices of drugs in the antiinfective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications increased a mean of 195%, and prices of topical corticosteroids increased a mean of 290% during the study period. Selected generic drugs surveyed in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Conclusions and Relevance  The price of prescription dermatologic drugs rose considerably from 2009 to 2015, with the vast majority of price increases occurring after 2011. Percent increases for multiple, frequently prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services.

Introduction

The rising price of health care has far-reaching repercussions for the American economy. Now that the Baby Boomer generation (1946-1964) is reaching the age at which they are eligible for Medicare, high health care prices directly affect federal spending and add to the national deficit. The Patient Protection and Affordable Care Act attempts to reduce long-term health care expenditures through a variety of mechanisms, such as preventive care, patient responsibility, and competition among health care professionals. The landmark health care reform, however, has done little to curb the quickly rising price of prescription drugs and ensure that medications remain within reach for the patients who need them.

Of all members of the Organization for Economic Cooperation and Development, the United States pays the most per capita for prescription drugs.1 As health insurance programs become more restrictive with their formularies or promote policies with high deductibles, patients are increasingly being forced to pay retail prices out of pocket for the drugs that will help them most. In 2014, 19% of Americans between the ages of 19 and 64 years chose not to fill at least 1 prescription owing to cost.2 Although the Patient Protection and Affordable Care Act aimed to protect patients from facing unexpectedly large medical bills, patients across the United States now face the reality that there is little protection from health plans excluding coverage for expensive prescription items.

Researchers and legislators have examined the high prices for new chemotherapy drugs and have cited the unexpected Average Wholesale Price increases for select generic medications.35 With regard to the dermatologic sector, Payette and Grant-Kels6 found considerable variability by pharmacy, state, and payer in the prices of brand-name prescription drugs and their generic equivalents at a single time point. To our knowledge, the rising retail prices of brand-name medications within the dermatologic sector, however, have yet to be examined systematically over time. We endeavored to gather data over time for the out-of-pocket US retail prices of commonly prescribed brand-name dermatologic drugs to better elucidate the degree to which these drugs’ prices increased over time.

Methods

Four national chain pharmacies in the West Palm Beach, Florida, area—specifically, Costco, CVS, Sam’s Club, and Walgreens—were initially surveyed in 2009. Similar surveys were completed in 2011, 2014, and 2015 by the same 4 pharmacy locations initially surveyed in 2009. Communication with the pharmacists in each chain indicated that there was no variation in prices among chain locations within Palm Beach County, although prices outside the county may exhibit small variation owing to geographical location. The surveys began with, “In order to better serve our patients and be more aware of the costs to our uninsured patients and those with high deductibles, would you please provide the costs for the following medications and fax back your response.” In 2009, we included 72 different brand-name medications in the survey. Expanded surveys were used in the same manner in 2011, 2014, and 2015 with some modifications owing to the introduction and discontinuation of relevant medications. We aimed to collect price data for either a full course of treatment or 1 month of therapy for a drug’s main indication. Analysis was conducted from August 1 to 15, 2015.

Nineteen brand-name drugs with data available in all 4 surveys were selected for final analysis owing to their frequency of prescription, diseases treated, or unusual price increase during the survey period. The drugs selected were Altabax, 15 g; Benzaclin, 50 g; Carac cream, 30 g; Clobex spray, 4 oz; Cloderm cream, 30 g; Cutivate lotion, 120 mL; Derma-Smoothe FS oil, 4 oz; Finacea, 50 g; Olux-E foam, 100 g; Oracea, 40 mg; Oxistat cream, 30 g; Oxsoralen-Ultra, 10 mg; Retin-A Micro, 0.1%, 50 g; Solaraze gel, 100 g; Taclonex, 60 g; Targretin gel, 1 tube; Tazorac cream, 0.1%, 60 g; Xolegel, 30 g; and Soriatane, 25 mg. Recorded prices for each drug were averaged across the 4 pharmacies for comparison over time. The 19 brand-name drugs were then grouped into one of the following treatment indication groups: acne and rosacea, psoriasis, topical corticosteroids, antiinfectives, and antineoplastics. The antineoplastic class did not include systemic medications for metastatic melanoma or basal cell carcinoma as such medications were not available in 2009 and are infrequently prescribed by community-based physicians. Institutional review board approval was waived by the University of Miami Miller School of Medicine.

Results

All 4 pharmacies returned completed surveys via fax within 1 week of distribution in all 4 survey periods, for an overall response rate of 100%. Between 2009 and 2015, prices of all surveyed classes of brand-name drugs increased; the mean increase was 401% (Figure 1). Prices of topical antineoplastic drugs had the greatest mean absolute and percentage increase ($10 926.58 [1240%]). Prices of drugs in the antiinfective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%).

Prices of the surveyed acne and rosacea medications—Benzaclin; Finacea; Oracea; Retin-A Micro, 0.1%; and Tazorac cream, 0.1%—increased a mean of 195% between 2009 and 2015, although the price of Retin-A Micro, 0.1%, increased approximately 5-fold in the same period (Figure 2).

Prices of the topical corticosteroids—Clobex spray, Cloderm cream, Cutivate lotion, Derma-Smoothe FS oil, and Olux-E foam—increased considerably during the 6-year survey period despite the availability of alternative brands or generic formulations for most classes of topical corticosteroids. Overall, prices in this group of medications increased a mean of 290% between 2009 and 2015. The greatest percentage price increase in this category was for Derma-Smoothe FS oil (606%); the smallest percentage price increase was for Clobex spray (146%).

For survey purposes, either the cost for a full course of treatment or the cost of 1 month of therapy was recorded. In the case of drugs used primarily for psoriasis, however, the amount of medication used per month can vary greatly among patients depending on the surface area being treated, the frequency of treatments, and the patient’s weight. The survey therefore recorded the prices of 50 capsules of Oxsoralen-Ultra, 10 mg; 30 capsules of Soriatane, 25 mg; and a 60-g tube of Taclonex. Like the other classes of surveyed drugs, prices of these 3 medications also increased between 2009 and 2015, with a mean increase of 180%. While the prices of Taclonex and Soriatane doubled between 2009 and 2015, the price of Oxsoralen-Ultra more than quadrupled, rising from $1227.32 to $5204.31 (Figure 3).

Many of the topical medications used for treating bacterial and fungal diseases have become available in generic formulations, and in some cases brand-name products were no longer available for comparison throughout the entire survey period. Prices of the 3 antiinfectives analyzed in this study—Altabax, Oxistat cream, and Xolegel—increased between 2009 and 2015, rising a mean of 309%. In that period, the price of Oxistat cream increased the most in both absolute and percentage terms, rising 7-fold from $76.50 in 2009 to $544.66 in 2015.

Solaraze gel and Carac cream are used primarily for treating actinic keratoses. Additional treatments became available after 2009 and were therefore not eligible to be included in this survey. Targretin gel is used to treat cutaneous T-cell lymphoma. Patients typically require more than one 60-g tube per month. The medications in the antineoplastic group had the most notable price increases, rising a mean of 1240% during the 6-year study period. Both Carac cream and Targretin gel had the largest overall percentage increase, each rising 1697% between 2009 and 2015. In addition, of all 19 drugs analyzed, Targretin gel increased the most in absolute price during the study period, rising $28 633.34 per tube.

Overall, there has been a general increase in the price of surveyed prescription dermatologic medications, but this increase is particularly pronounced after 2011. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled during the study period, with the vast majority of price increases occurring after 2011 (Table).

We surveyed generic dermatologic drugs in 2011 and 2014 and found that there is considerable variation in pricing by different pharmacies. Prices of the surveyed generic drugs increased a mean of 279% in the 3-year period. Some prices remained relatively unchanged between 2011 and 2014 (Figure 4). Prices of other commonly prescribed items, many of which were available in generic formulations for more than a decade, increased dramatically—in particular, fluocinonide (Lidex) and nystatin-triamcinolone (Mycolog-II), with the price of the latter increasing 10-fold between 2011 and 2014, rising from $9.15 to $103.88 for a 30-g tube.

Discussion

The increase in prices of the surveyed medications far outpaced the national consumer price index inflation rate of 11% between 2009 and 2015.7 Furthermore, the prices of prescription drugs are increasing at a rate that outpaces inflation, growth of gross domestic product, and health care expenditures in other sectors. While the prices of physician and clinical services rose less than 0.1% throughout 2013, prescription drug spending increased 2.5% in that same time period; the Centers for Medicare & Medicaid Services attributes the disproportionate increase to the 0% payment updates to clinicians and increases in prices for brand-name and specialty drugs as well as increased spending on new medications and increased use of medications.8

Four chain pharmacies in the West Palm Beach, Florida, area were surveyed because the original intention was to educate Florida dermatologists about the prices of many of the drugs they frequently prescribe. Although follow-up surveys were sent to the same 4 chain pharmacies in South Florida, we hold that the price data gathered reflect national price trends since we specifically queried national chain pharmacies’ prices. Prices at local, independently owned pharmacies may show additional variation; therefore, we did not investigate such pharmacies.

Average Wholesale Price was not evaluated because it is not reflective of the true retail price of prescription items nor out-of-pocket costs to consumers. In addition, Average Wholesale Price is not a reliable indicator of wholesale costs to individual pharmacies because prices vary with wholesale distributors as well as bulk purchasing.9

Although the surveys in 2011 and 2014 were expanded to approximately 100 commonly prescribed medications, comparison of data was limited to 19 brand-name drugs whose data were available for all 4 surveys. These 19 medications were chosen to ensure presence of a cross-section in each major dermatologic therapeutic category: acne and rosacea, antiinfectives, psoriasis, antineoplastics, and corticosteroids. These 19 drugs were also selected to ensure that the chosen drugs were not part of the product portfolio for the same parent company; analyzed drugs represented products from multiple small-, mid-, and large-size companies.

New medications entering the market tend to be more expensive, and their prices are justified by the costs associated with research, development, and obtaining approval from the US Food and Drug Administration. However, many of the drugs surveyed, such as Carac cream, Derma-Smoothe FS oil, Cutivate lotion, Targretin gel, and nystatin-triamcinolone, have been available for more than 10 years and are associated with some of the highest percentage increases in price.

Prescription drugs generally cost more in the United States than anywhere else in the world.10 In countries outside the United States, drugs sell for a fraction of their US price. For example, in the United States, Gilead’s drug for hepatitis C, Sovaldi, is priced at $84 000 for a full 12-week course of treatment; in Egypt and Brazil, Gilead sells a 12-week supply of brand-name Sovaldi for $840, 1% of its US price.11,12 Mergers and acquisitions enable pharmaceutical companies to corner specific drug markets, thereby using a large market presence to leverage higher prices for products within a therapeutic class.13 Drugs may retain their patent longer than originally intended. For example, the main patent for Enbrel was set to expire in October 2012, yet owing to changes in patent law the product remains protected from generic competition through 2028.14 Medication shortages owing to manufacturing complications and limited availability of active ingredients have been implicated as the reason for significant price increases for affected medications.13 Oxsoralen-Ultra and generic doxycycline were 2 such affected drugs; however, both medications are now readily available and are no longer on the US Food and Drug Administration list of drug shortages.1517 Nevertheless, the prices of these medications have not returned to their prior price levels.4

Medicare legally cannot negotiate drug prices for beneficiaries, unlike government health programs in other countries such as France and Australia, the US Department of Veterans Affairs, and the US Department of Defense’s Tricare program.18 Although patients who have prescription drug coverage may not see the retail price of these medications directly at the pharmacy, high drug prices are reflected in increasingly expensive monthly insurance premiums. Without insurance, patients pay high, retail list prices for their medications. As insurance formularies become more restrictive and because Medicare patients are ineligible for pharmaceutical coupon savings, even insured patients often pay retail prices out of pocket for their medications.19

We did not detect any specific trend to explain the significant increase in the costs of dermatologic prescription drugs, nor did we investigate reasons for the price increases. Further consideration should be given to that subject to focus on ways to reduce prices in the future.

Conclusions

The prices of brand-name and generic dermatologic prescription drugs have increased significantly in recent years, with the greatest increases seen in the antineoplastic sector. Percent increases for multiple, frequently prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services.

Back to top
Article Information

Accepted for Publication: August 24, 2015.

Corresponding Author: Steven P. Rosenberg, MD, Department of Dermatology, The Miller School of Medicine at the University of Miami, 470 Columbia Dr, Ste 102A, West Palm Beach, FL 33409 (palmbeachderm@yahoo.com).

Published Online: November 25, 2015. doi:10.1001/jamadermatol.2015.3897.

Author Contributions: Dr Rosenberg and Ms Rosenberg had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: M. E. Rosenberg.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: M. E. Rosenberg.

Administrative, technical, or material support: Both authors.

Study supervision: M. E. Rosenberg.

Conflict of Interest Disclosures: None reported.

References
1.
Gagnon  M-A, Wolfe  S. Mirror, mirror on the wall: Medicare Part D pays needlessly high brand-name drug prices compared with other OECD countries and with US government programs.http://carleton.ca/sppa/wp-content/uploads/Mirror-Mirror-Medicare-Part-D-Released.pdf. Published July 23, 2015. Accessed August 19, 2015.
2.
Collins  SR, Rasmussen  PW, Doty  MM, Beutel  S. The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014.http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2015/jan/1800_collins_biennial_survey_brief.pdf?la=en. Published January 2015. Accessed August 19, 2015.
3.
Mailankody  S, Prasad  V.  Five years of cancer drug approvals: innovation, efficacy, and costs. JAMA Oncol. 2015;1(4):539-540.PubMedArticle
4.
US Senate. Ranking member Cummings and Chairman Sanders investigate staggering price increases for generic drugs.http://www.sanders.senate.gov/download/face-sheet-on-generic-drug-price-increases. Published 2014. Accessed April 1, 2015.
5.
Alpern  JD, Stauffer  WM, Kesselheim  AS.  High-cost generic drugs—implications for patients and policymakers. N Engl J Med. 2014;371(20):1859-1862.PubMedArticle
6.
Payette  M, Grant-Kels  JM.  Generic drugs in dermatology: part II. J Am Acad Dermatol. 2012;66(3):353.e1-353.e15.PubMedArticle
7.
Bureau of Labor Statistics, US Dept of Labor. CPI inflation calculator.http://www.bls.gov/data/inflation_calculator.htm. Published 2015. Accessed August 19, 2015.
8.
Centers for Medicare & Medicaid Services. National health expenditures 2013 highlights.https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Published 2014. Accessed April 1, 2015.
9.
Gencarelli  DM.  Average Wholesale Price for prescription drugs: is there a more appropriate pricing mechanism? NHPF Issue Brief. 2002;(775):1-19.PubMed
10.
Greene  W. The emergence of India's pharmaceutical industry and implications for the US generic drug market. Washington, DC: US International Trade Commission, Office of Economics. Publication 2007-05-A. http://www.usitc.gov/publications/332/EC200705A.pdf. Published May 2007. Accessed August 19, 2015.
11.
Gilead Sciences. Hepatitis B and C treatment expansion.http://www.gilead.com/~/media/files/pdfs/other/hepatitis%20b%20and%20c%20treatment%20expansion%20-%20february%202015.pdf. Published February 2015. Accessed August 19, 2015.
12.
Mosendz  P. $1,000-a-day hepatitis C miracle drug gets a major price cut, just not in the US.The Wire. http://www.thewire.com/global/2014/04/1000-a-day-hepatitis-c-miracle-drug-gets-a-major-price-cut-just-not-in-the-us/360505/. Published April 11, 2014. Accessed August 19, 2015.
13.
US Government Accountability Office. Brand-name prescription drug pricing: lack of therapeutically equivalent drugs and limited competition may contribute to extraordinary price increases. Publication GAO-10-201. http://www.gao.gov/new.items/d10201.pdf. Published December 2009. Accessed August 19, 2015.
14.
Pollack  A. Patent for Amgen drug may undercut health care plan. New York Times. November 23, 2011:B7.
15.
Valeant Pharmaceuticals International Inc. Valeant pharmaceuticals resumes shipment of Oxsoralen-Ultra: Valeant investor relations. http://www.prnewswire.com/news-releases/valeant-pharmaceuticals-resumes-shipment-of-oxsoralen-ultrar-96966464.html. Accessed February 8, 2016.
16.
Centers for Disease Control and Prevention. Doxycycline shortage.http://www.cdc.gov/std/treatment/doxycyclineShortage.htm. Accessed April 1, 2015.
17.
US Food and Drug Administration, US Dept of Health and Human Services. FDA drug shortages: current and resolved drug shortages and discontinuations reported to FDA.http://www.accessdata.fda.gov/scripts/drugshortages/. Revised 2015. Accessed April 1, 2015.
18.
Dicken  JE. Prescription Drugs: an Overview of Approaches to Negotiate Drug Prices Used by Other Countries and US Private Payers and Federal Programs. Washington, DC: US Government Accountability Office; January 11, 2007. Publication GAO-07-358T.
19.
Department of Health and Human Services, Office of the Inspector General. Manufacturer safeguards may not prevent copayment coupon use for Part D drugs. Publication OEI-05-12-00540. http://oig.hhs.gov/oei/reports/oei-05-12-00540.pdf. Published September 2014. Accessed August 19, 2015.
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