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A Comparison of Brand-Name Drug Prices between Canadian-Based Internet Pharmacies and Major U.S. Drug Chain Pharmacies

Bradley S. Quon, MD, MBA; Rafael Firszt, MD, MBA; and Mark J. Eisenberg, MD, MPH
[+] Article, Author, and Disclosure Information

From St. Paul's Hospital and Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and Montréal Children's Hospital and Jewish General Hospital, McGill University, Montréal, Québec, Canada.

Acknowledgments: The authors thank Derek Hart, MBA, for study design and Russell Steel, PhD, for statistical analysis.

Grant Support: None.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Mark J. Eisenberg, MD, MPH, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Cote Ste. Catherine Road, Suite A-118, Montréal, Québec, H3T 1E2 Canada; e-mail, meisenberg@epid.jgh.mcgill.ca

Current Author Addresses: Dr. Quon: Suite 31, 795 West 8th Avenue, Vancouver, British Columbia V5Z 1C9, Canada.

Dr. Firszt: 5618 Edgemore, Montréal, Québec H4W 1V5, Canada.

Dr. Eisenberg: Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Cote Ste. Catherine Road/Suite A-118, Montréal, Québec H3T 1E2, Canada.

Author Contributions: Conception and design: B.S. Quon, R. Firszt, M.J. Eisenberg.

Analysis and interpretation of the data: B.S. Quon, R. Firszt, M.J. Eisenberg.

Drafting of the article: B.S. Quon, R. Firszt, M.J. Eisenberg.

Critical revision of the article for important intellectual content: B.S. Quon, R. Firszt, M.J. Eisenberg.

Final approval of the article: B.S. Quon, R. Firszt, M.J. Eisenberg.

Statistical expertise: M.J. Eisenberg.

Administrative, technical, and logistical support: M.J. Eisenberg.

Collection and assembly of data: B.S. Quon, R. Firszt.

Ann Intern Med. 2005;143(6):397-403. doi:10.7326/0003-4819-143-6-200509200-00004
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Of the 44 brand-name medications examined (Table 2), the 3 largest therapeutic classes represented were the cardiovascular, alimentary/metabolism, and central nervous system classes, which included a total of 30 medications combined (68%). The cardiovascular class, which includes the statins, was the largest, with a total of 13 medications (30%). These results correspond closely to data published by Intercontinental Marketing Services Canada in 2003. When total Internet pharmacy sales were used, these 3 classes represented 57% of the studied drugs, with the cardiovascular class leading at 35% (14). Even though all medications were brand name, 36 of the 44 medications we examined were patented (15).

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Comparison of medication prices between Canadian Internet pharmacies and U.S. drug chain pharmacies with online pricing.

Each data point represents the average price of 1 unit dose of the same medication purchased in Canada and in the United States. Generic names and manufacturers are as follows: Actos (pioglitazone) (Eli Lilly, Indianapolis, Indiana); Cialis (tadalafil) (Eli Lilly, Indianapolis, Indiana); Levitra (vardenafil) (Bayer, Pittsburgh, Pennsylvania); Nexium (esomeprazole) (AstraZeneca, Wilmington, Delaware); Viagra (sildenafil) (Pfizer, New York, New York); and Zyprexa (olanzapine) (Eli Lilly, Indianapolis, Indiana).

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Submit a Comment/Letter
U.S. and Canadian Brand-Names Prove Costly
Posted on September 28, 2005
John M Hayes
Denver VAMC
Conflict of Interest: None Declared

To the Editor: In the September 20, 2005 issues of Annals, Quon et al. present an interesting analysis of potential financial advantages of purchasing brand-name medicines from Canadian internet pharmacies (1). From the patients' perspective, the omission of generic drugs from this study may greatly limit the usefulness of these data. Patients will be concerned about the total price of medicines prescribed, not whether or not they are using a brand name or generic drug.

We have previously shown important generic savings in a U.S. internet pharmacy with a typical cardiovascular regimen (Metoprolol 50mg bid, Lisinopril 20mg qd, Lovastatin 40mg qd) (2). Using similar methods as Quon et al's study at Pharmacychecker.com (3), we found our annual generic regimen cost to be 56% less than the same regimen from a Canadian based pharmacy ($460 vs $1052).

Other studies have remarked on the broad absolute savings that generic substitution patterns could have in the U.S. (4) While brand name medicines may be less expensive if we look across our northern border, the first step U.S. internists should take when looking out for the financial impact of prescriptions is to consider the many evidence-based equipotent generic options here in this country.

John M. Hayes, MD Allan Prochazka, MD, MS Denver Veterans Affairs Medical Center Denver, CO 80209

The views expressed within this work are the private opinions of the authors and do not represent the official policy of the Denver VAMC or of the Department of Veterans Affairs.

1. Quon BS, Firszt R, Eisenberg MJ. A Comparison of Brand-Name Prices between Canadian-Based Internet Pharmacies and Major U.S. Drug Chain Pharmacies. Ann Intern Med. 2005;143(6):397-403. [PMID: 16172438] 2. Hayes JM, Walczak H, Prochazka A. Comparison of Drug Regimen Costs Between the Medicare Prescription Discount Program and Other Purchasing Systems. JAMA. 2005;294(4):427-8. [PMID: 16046648] 3. Pharmacychecker.com. Accessed at www.pharmacychecker.com on 27 September 2005. 4. Potential savings from substituting generic drugs for brand-name drugs: medical expenditure panel survey, 1997-2000. Ann Intern Med. 2005 Jun 7;142(11):891-7. [PMID: 15941695]

Conflict of Interest:

None declared

Only a Minority of Patients Can Use Canadian Drugs
Posted on October 7, 2005
Michael B Rothberg
Baystate Medical Center
Conflict of Interest: None Declared

After comparing prices at American and Canadian internet pharmacies, Quon, et al conclude that "Americans purchasing brand-name medications from Canadian Internet pharmacies can realize substantial savings."(1) Although this is undoubtedly true for a small number of individuals, it in no way addresses the needs of the two-thirds of Americans who feel drug prices are unreasonably high. As the authors' point out, re-importation accounts for less than 1% of the US market, yet even this amount of reimportation has led to rapidly rising prices at Canadian pharmacies over a 6-month period.

The companies that manufacture the drugs would rather cut off all supply to 30 million Canadians than let Canada set the prices for 300 million Americans. Pharmaceutical companies have already begun limiting sales to Canada, and Merck announced in January that it would no longer sell to Canadian pharmacies that export to the US.(2) The Canadian Health Minister, aware of the threat to Canadian supplies, last summer proposed legislation to prohibit bulk exports to US citizens without Canadian doctors.(3)

Even though a majority of Americans favor Canadian-style price controls, industry lobbying makes the passage of such controls unlikely. An American-style alternative exists. In extending prescription drug coverage to Medicare patients, Congress missed an opportunity to lower drug prices by allowing the government to negotiate prices on behalf of 40 million Medicare beneficiaries. The Veterans Administration routinely obtains discounts of 16% to 41% using this strategy.(4) Rather than turning to the Canadian government to secure drug discounts for us, we should repeal the anti-competitive language in the current Medicare law.


1. Quon BS, Firszt R, Eisenberg MJ. A Comparison of Brand-Name Drug Prices between Canadian-Based Internet Pharmacies and Major U.S. Drug Chain Pharmacies. Ann Intern Med. 2005;143(6):397-403.

2. Lauerman J. Merck Shuts Off Canadian Pharmacies Selling to U.S. Bloomberg.com. 2005. Available at http://www.bloomberg.com/apps/news?pid=10000082&sid=ai9RdezyHWRE&refer=canada. Accessed October 7, 2005

3. Duff-Brown B. Health minister says Canada to restrict export of medications. Boston Globe 2005 June 29.

4. Sales MM, Cunningham FE, Glassman PA, Valentino MA, Good CB. Pharmacy benefits management in the Veterans Health Administration: 1995 to 2003. Am J Manag Care. 2005;11(2):104-12.

Conflict of Interest:

None declared

Authors' Response to Letter to the Editor
Posted on November 23, 2005
Mark J. Eisenberg
Jewish General Hospital/McGill University
Conflict of Interest: None Declared

We agree with Dr. Rothberg that Americans should not have to look north of the border to access more affordable medications. The underlying premise of our article was not to promote the purchase of Canadian pharmaceuticals, but rather, to quantify and highlight the differences in brand-name medication prices between the two countries. The average 24% price savings per unit cited in our article should serve as a benchmark for Congress to target in lowering brand-name medication prices domestically for all Americans(1). Canadian style strategies to lower medication prices, including price control through the Patented Medicines Price Review Board (PMPRB) and the use of market-based competition through provincial drug reimbursement formularies, have proven to be effective. Importantly, Americans can look within their own borders to observe the benefits of drug coverage formularies. As Dr. Rothberg points out, this strategy has been used successfully by the Veterans Administration to lower medication prices for US government employees(2). Congress will need to find creative ways to extend a formulary-based strategy to benefit low-income class Americans who are without prescription drug coverage and who ironically pay the highest prices for their medications.

1 Quon, et al. A comparison of brand-name drug prices between Canadian-based Internet pharmacies and major U.S. drug chain pharmacies. Annals of Internal Medicine. 143(6):397-403, 2005 Sep 20.

2 http://www.pbm.va.gov/PBM/prices.htm. Accessed November 17th, 2005

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Price Comparison for Brand Name Drugs Purchased through the Internet from Canada- and U.S.-based Pharmacies

The summary below is from the full report titled “A Comparison of Brand-Name Drug Prices between Canadian-Based Internet Pharmacies and Major U.S. Drug Chain Pharmacies.” It is in the 20 September 2005 issue of Annals of Internal Medicine (volume 143, pages 397-403). The authors are B.S. Quon, R. Firszt, and M.J. Eisenberg.


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