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Medicine and Public Policy |

The International Pharmaceutical Market as a Source of Low-Cost Prescription Drugs for U.S. Patients

Aaron S. Kesselheim, MD, JD; and Niteesh K. Choudhry, MD, PhD
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From Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.


Acknowledgment: The authors thank Kevin Outterson, Michael Reich, Rahul Rajkumar, and Frank May for their comments on earlier drafts of the manuscript.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Aaron S. Kesselheim, MD, JD, Division of Pharmacoepidemiology and Pharmacoeconomics, 1620 Tremont Street, Suite 3030, Boston, MA 02120; e-mail, akesselheim@partners.org.

Current Author Addresses: Drs. Kesselheim and Choudhry: 1620 Tremont Street, Suite 3030, Boston, MA 02120.


Ann Intern Med. 2008;148(8):614-619. doi:10.7326/0003-4819-148-8-200804150-00006
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In response to increasing prescription drug costs, more U.S. patients and policymakers are importing less-expensive pharmaceutical products from other countries. Large-scale prescription drug importation is currently illegal, but the U.S. Food and Drug Administration permits individuals to bring in 90-day supplies of drugs for personal use. As patient use of foreign-bought drugs has increased, federal legislators have continued to debate the full legalization of importation. Three factors help guide whether U.S. patients and policymakers can rely on other countries as sources of imported prescription drugs: whether the safety of the product can be ensured, how the import price compares with domestic prices, and how importation might affect the exporting country's pharmaceutical market. In wealthier countries with active regulatory systems, drug safety can be adequately ensured, and brand-name products are usually less expensive than in the United States (although generic drugs may be more expensive). However, implementing large-scale importation can negatively impact the originating country's market and can diminish the long-term cost savings for U.S. consumers. In low- and middle-income countries, prices may be reduced for both brand-name and generic drugs, but the prevalence of unauthorized products on the market makes ensuring drug safety more difficult. It may be reasonable for individual U.S. consumers to purchase essential medicines from certain international markets, but the most effective way to decrease drug costs overall is the appropriate use of domestic generic drugs, which are available for almost every major therapeutic class.

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U.S. Pharmaceutical Options Improving
Posted on May 13, 2008
John M. Hayes
Milwaukee VA Medical Center and Denver VA Medical Center
Conflict of Interest: None Declared

To the editor: The recent article by Kesselheim and Choudry highlight important considerations in assessing the international market for lower cost pharmaceuticals. Soon after Medicare Part D was initiated, there was a clear cost benefit to patients in aggressively searching for non-Part D sources of brand name cardiovascular medicines.(1) The brand name regimen we have examined (Toprol XL 100 mg daily, Altace 10 mg daily, Lipitor 10 mg daily) went from $933 in 2005 at the best Canadian on-line price to $1048 in 2007.(2) The median price for the US Part D plans in the Denver 80220 zip code for this regimen went from $1731 to $1133 in the same time period. For comparison, a generic equipotent regimen (metoprolol 100 mg bid, lisinopril 20 mg qd, lovastatin 20 mg qd) dropped from a median of $744 in 2005 to $555 in 2007. In 2005 only one Part D plan had annual costs less than the best Canadian price whereas in 2007 many Part D plans (36.5%) now provide brand name medications at better prices than the best Canadian on-line source.(3)

In the two years since Part D inception, annual patient costs have fallen significantly for a typical brand name cardiovascular regimen while the lowest Canadian annual costs available have increased. Although in our studied regimen Toprol XL now has an approved generic equivalent which may contribute to lower costs for the brand name medication, we do not believe this alone can account for the decline. The recent fall in the US dollar relative to the Canadian dollar, certainly contributes to the lesser cost advantage of seeking brand name medications outside the US. In addition, generic equivalent regimens both inside and outside Part D plans continue to fall in price.

Given the shrinking cost advantage and the other difficulties of international drug purchase outlined by Kesselheim and Choudry, physicians should encourage Medicare patients to seek the Part D plans that cover their needs at the lowest cost and should prescribe generic alternatives whenever possible.

1) Hayes JM, Walczak, H, Prochazka A. Comparison of drug regimen costs between the Medicare prescription discount program and other purchasing systems. JAMA. 2005 Jul 27;294(4):427-8. PMID: 16046648

2) Information accessed December 2005 and Decmber 2007 at http://www.pharmacychecker.com

3) Information accessed December 2005 and Decmber 2007 at http://www.medicare.gov/

Conflict of Interest:

None declared

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