Shopping for Drugs: 2007

Studies | Health

No. 293
Thursday, November 16, 2006
by Devon Herrick, Ph.D.


Notes & Appendix

  1. In 2005 Americans spent more than $230.3 billion on prescription drugs.  Over-the-counter drugs probably increased total expenditure by an additional $20 billion.  See "Industry Facts-at-a-Glance, Rx Sales 2005," National Association of Chain Drug Stores.  Available at http://www.nacds.org/wmspage.cfm?parm1=507#retail.  Accessed June 6, 2006.  Consumer Healthcare Products Association put yearly OTC drug sales at $15 billion (excluding Wal-Mart).
  2. See, for example, James M. Hoffman, et al., "Projecting Future Drug Expenditures - 2004," American Journal of Health-System Pharmacists, Vol. 61, No. 2, February 2004, pages 145-158.
  3. A drug was either provided or prescribed in 64.8 percent of office visits.  The average number of prescriptions written is 2.25 per patient when they receive one during the course of an office visit.  David A. Woodwell and Donald K. Cherry, "National Ambulatory Medical Care Survey: 2002 Summary," National Center for Health Statistics, Advance Data from Vital and Health Statistics, No. 346, August 26, 2004.
  4. See "Industry Facts-at-a-Glance," National Association of Chain Drug Stores.  Available at http://www.nacds.org/wmspage.cfm?parm1=507#retail.  Accessed June 6, 2006.
  5. Ibid.
  6. "2002 Missouri Prescription Drug Pricing Survey," Public Issue Management, 2002. 
  7. Al Tompkins, "Monday Edition: Generic Drug Prices," KHOU (News 11, Houston), November 30, 2003.
  8. Fred Gebhart, "Chain Stores Top Generic Price Charts," Drug Topics, Drug Topics Supplements, April 3, 2006.  Also see Kathy Times, "Independents Often Beat Chains in Prescription Prices," NBC13.com, November 25, 2002.
  9. Although some of the following anecdotes are from regional surveys conducted by the news media, the results are consistent with a recent multistate survey by a research institute.  See RetireSafe.org, "Take the Rx Challenge: 2003 Retail Pharmacy Pricing Survey," Council for Government Reform, June 2003.
  10. Barbara West, "Massive Mark-Ups Found on Generic Drugs," WFTV (Channel 9, Orlando), October 21, 2002.
  11. Steve Wilson, "Steve Wilson Exposes Huge Prescription Drug Price Markups," WXYZ.com (Channel 7 Detroit), February 6, 2004.
  12. Editorial, "Generic Meds Not Panacea Some Believe," Iowa City Press-Citizen, June 18, 2003.
  13. ABC Action News, "Pill Patrol: Generic Drugs Marked Up as Much as 3,000 Percent," abcactionnews.com (WFTS ABC Action News Tampa, Fla.), November 27, 2003.
  14. Prices verified October 16, 2006 at MyFloridaRx.com.
  15. Prices verified on October 16, 2006 on DestinationRx.com.
  16. Julius A. Karash, "The $4 Drug Gambit," Kansas City Star, October 27, 2006.
  17. The 314 drugs includes different doses and forms of the same medications.  The number of chemically distinct medications is closer to 150. For a list of generic drugs and doses that Wal-Mart will sell at low prices, see http://www.usatoday.com/money/industries/health/drugs/walmart-druglist.pdf.  
  18. Julie Appleby, "Target Says It Will Match Wal-Mart's $4 Generic Drug Price," USA Today, September 21,2006.
  19. Wegmans has stores in New York, Pennsylvania, New Jersey, Virginia and Maryland. See http://www.wegmans.com/about/storeLocator/.
  20. "Wal-Mart Adds 12 States to $4 Generic Drug Plan," USA Today, October 26, 2006. Available at http://www.usatoday.com/money/industries/retail/2006-10-26-walmart-drugs_x.htm.
  21. The five states include Ohio, Illinois, Indiana, Kentucky and Michigan. Tracy Turner, "Supermarkets Offer Generic Drugs Free as Lure," Columbus Dispatch, October 25, 2006. Available at http://www.dispatch.com/health/health.php?story=dispatch/2006/10/25/20061025-A1-02.html.
  22. Tracy Turner, "Supermarkets Offer Generic Drugs Free as Lure."
  23. Price verified on October 16, 2006 on MyFloridaRx.com.
  24. Ibid.
  25. "Bid for Rx Web Site Now Online Using Auctions to Reduce Prescription Drug Costs," PharmaLive.com, August 17, 2006.
  26. Joe Vanden Plas, "Will BidRx Start a Drug Price War?" Wisconsin Technology Network, August 2, 2006.  Available at http://wistechnology.com/article.php?id=3196.  Accessed September 6, 2006.
  27. Newt Gingrich and James Frogue, "Sticker Shock Could Help with Healthcare Costs," The Hill, March 8, 2006.  Also see "A Proposal for an Electronic Comparison System and Personal Health Formulary: Implementing a ‘Travelocity-style' Model of Prescription Drug Purchasing," Center for Health Transformation, Issue Brief, January 6, 2004.
  28. Newt Gingrich, "Taking Health Care to the Next Level," Des Moines Register, September 1, 2005.
  29. The Web site is www.Rxaminer.com; address confirmed on October 16, 2006.
  30. John D. Piette, Michele Heisler and Todd H. Wagner, "Cost-Related Medication Underuse: Do Patients with Chronic Illnesses Tell Their Doctors?" Archives of Internal Medicine, Vol.164, No. 16, September 13, 2004, pages 1,749-1,755.
  31. Jeffrey A. Lieberman, et al. (Clinical Antipsychotic Trials of Intervention Effectiveness Investigators), "Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia," New England Journal of Medicine, Vol. No. September 22, 2005, pages 1,209-1,223.
  32. There are two types of antihistamines: first-generation (sedating) and second-generation (non-sedating).
  33. First-generation antihistamines also include Clistin (Carbinoxamine), Tavist (Clemastine), Chlor-Trimeton (Chlorpheniramine) and Dimetane (Brompheniramine).
  34. Philipp S. Muether and Jack M. Gwaltney Jr., "Variant Effect of First- and Second-Generation Antihistamines as Clues to Their Mechanism of Action on the Sneeze Reflex in the Common Cold," Clinical Infectious Diseases, November 1, 2001, pages 1,483-88.
  35. Ibid.
  36. Allegra was 60mg, Zyrtec 10mg and Clarinex 5mg.  Prices surveyed at Costco.com on October 2006.
  37. Prices surveyed at Drugstore.com on October 2006.
  38. Price of 10mg Claritin for 100 doses purchased 50 tablets at a time from Walgreens.com.  Price surveyed November 2006.  The price for Loratadine (10mg) was based on buying two bottles of 150 tablets packaged together.  Prices were surveyed on May 24, 2006 at Sam's Club (Greenville at Park Lane), Dallas, Texas.
  39. Benadryl (25mg) is available in qualities of 100 for $14.29 and generic diphenhydramine (25mg) is available in quantities of 200 for $7.79 at Drugstore.com.  Price sampled on November 2006.
  40. Dose for Chlorpheniramine tends to be from 4mg to 12mg.  Raymond Woosley conducted research which led him to believe that it is effective at doses low enough to be nonsedating.  See Matthew Herper, "Five Generic Drugs, Cheap But Ignored," Forbes.com, November 2, 2001.  Available at http://www.forbes.com/2001/11/02/1102drugs.html.  Accessed November 2006.  Also see Stephen Hall, "The Claritin Effect: Prescription for Profit," New York Times Magazine, March 11, 2001.
  41. Drugstore.com.  Price surveyed June 7, 2006.
  42. G.G. Kay and A.G. Harris, "Loratadine: A Non-Sedating Antihistamine; Review of its Effects on Cognition, Psychomotor Performance, Mood and Sedation," Clinical & Experimental Allergy, Vol. 29, Supplement 3, July 1999, pages 147-50.  Also see G.G. Kay et al., "Initial and Steady-State Effects of Diphenhydramine and Loratadine on Sedation, Cognition, Mood, and Psychomotor Performance," Archives of Internal Medicine, Vol. 10, No. 157, November 1997, pages 2350-56.
  43. Calculation was based on $7.79 for 200 tablets.  Cost per tablet would vary based on shipping and dosage.  This is especially true of cheaper medications like OTC drugs. 
  44. "Treating Allergies, Hay Fever, and Hives: The Antihistamines," Consumers Union, Consumer Reports Best Buy Drugs, August 2005.  Available at http://www.crbestbuydrugs.org/PDFs/Antihistamines.pdf.  Accessed June 6, 2006.
  45. Purportedly, Prilosec cures 94 percent of ulcers after four weeks of use.  The comparable rate for the older H2 antagonists, such as Zantax, is 70 percent to 80 percent.  Merrill Goozner, The $800 Million Pill: The Truth Behind the Cost of New Drugs (Berkley, Calif.: University of California Press, 2004), chapter 8.
  46. IMS Health, November 2003, cited in Michelle L. Kirsche, "Outlook Bright for 2004 Blockbusters - Chain Pharmacy - Boost in Prescription Drug Sales Is Anticipated as Result of New Coverage Provided to 35 Percent to 40 Percent of U.S. Seniors Currently without Prescription Drug Insurance," Drug Store News, January 19, 2004.  Data for October 2002 to September 2003.
  47. Gardiner Harris, "F.D.A. Approves Over-Counter Sales of Top Ulcer Drug," New York Times, June 21, 2003.
  48. Purchasing 100 20mg doses of Nexium (30 doses at a time) from Drugstore.com costs $493.33.  Price sampled on November 2006.
  49. Purchasing 100 30mg doses of Prevacid (30 doses at a time) from Drugstore.com costs $509.97.  Price sampled on November 2006.
  50. Purchasing 100 doses of Nexium (30 capsules at a time) would cost $436.57 at Costco.com.  Switching to Protonix and purchasing larger quantities (40 at a time), Protonix would bring the cost of 100 doses down to $353.16 at RxUSA.com. 
  51. The price for 100 capsules of Prilosec 20mg at Costco.com is $61.88 if purchased 42 at a time.  Price was verified on November 2006.  Consumers Union rates Prilosec a Best Buy.  See "Drugs to Treat Heartburn, Ulcers and Stomach Acid Reflux: The Proton Pump Inhibitors," Consumers Union, Consumer Reports Best Buy Drugs, November 2004.  Available at http://www.crbestbuydrugs.org/PDFs/Antihistamines.pdf. Accessed June 6, 2006.
  52. Zantac (Ranitidine), Pepcid (Famotidine) and Tagamet (Cimetidine) are histamine H2-receptor antagonists.
  53. Ranitidine is available over the counter in 75mg tablets but is often prescribed in 150mg or even 300mg doses.
  54. In this example, purchasing 100 150mg doses would require buying 240 75mg tablets and taking two at a time.  This is often more economical than purchasing the 150mg prescription strength.  Price Members Mark Ranitidine, available in packages of 240 75mg tablets, costs $5.88 at Sam's Club, 8282 Park Lane, Dallas, Texas.  Price verified on November 2006. 
  55. Price verified June 6, 2006.
  56. Purchased in quantities of 260 10mg tablets for $7.42 at Sam's Club, 8282 Park Lane, Dallas, Texas.  A 40mg dose requires four tablets, for a cost of 11.42 cents per dose. Price verified June 6, 2006.  Similar price at Costco.com November 2006. 
  57. Annette Tuffs, "Only 6% of Drug Advertising Material Is Supported by Evidence," British Medical Journal, Vol. 328, No. 7438, February 28, 2004. 
  58. Pat Kelly, "DTC Advertising's Benefits Far Outweigh Its Imperfections," Health Affairs, Web Exclusive, April 28, 2004; Joel S. Weissman et al., "Physicians Report on Patient Encounters Involving Direct-to-Consumer Advertising," Health Affairs, Web Exclusive, April 28, 2004.
  59. An exception to this rule is direct-to-consumer advertising of OTC products.  A drug company launching a name- brand drug for use over the counter may well advertise to gain market share for their product.  Here again, consumers should be wary.  Name-brand OTC products generally sell for more than their generic competitors' products.
  60. Bruce Japsen, "AMA Mulls Backing Limits on TV Drug Ads," Chicago Tribune, June 1, 2006.
  61. In 2000, about $7.9 billion in drugs were distributed free as samples - about half of the $15.7 billion the pharmaceutical industry spent on marketing.  The retail value of free samples increased to $16 billion by 2004.  Drug companies employ an estimated 90,000 drug industry reps, and spent $22 billion in 2003 to inform physicians about their products and influence prescribing behavior.  For an exposé on many of the drug industry's marketing efforts, see Jeff Gammage and Karl Stark, "Under the Influence," Philadelphia Inquirer, March 9, 2002.  Also see Liz Szabo, "Health Systems Cutting Costs by Closing Door on Drug Reps," USA Today, August 25, 2004.
  62. Leigh Page, "More Clinics Ban Drug Samples, Citing Cost, Safety Concerns," American Medical News, October 16, 2000.
  63. James Frederick, "Mandatory Mail Battle Heats Up as Michigan, Chains Lay Gauntlet," Drug Store News, February 16, 2004.
  64. Price surveys conducted June 1, 2004.
  65. See Diane West, "Mail-Order Rx Chips Away at Retail Sales," Drug Store News, May 20, 2002.
  66. All prices are for Atenolol 50mg.  Prices surveyed October 16, 2006, at DestinationRx.com.
  67. Prices verified on October 16, 2006, at Drugstore.com.
  68. Purchase made May 24, 2006, at Sam's Club, Greenville at Park Lane, Dallas, Texas.
  69. Price verified with DestinationRx.com on June 5, 2006.
  70. Amanda Gardner, "How to Break a Blockbuster Drug in Half: Man Invents Device to Cut Odd-Shaped Viagra Pill," HealthScout News, December 5, 2002.
  71. Information obtained from Parrish Blaszka (communications director), Precision Pill Splitters (www.precisionpillsplitters.com).
  72. Ibid.  A pill bed is a template designed for the exact shape and thickness of a specific dose of medications.  According to the manufacturer, some common medications that may be candidates for quartering are Accupril, aspirin, Fosamaxx, Imitrex Oral, Levaquin, Lipitor, Norvasc, Pravachol, Viagra, Vioxx, Zocor, Zyprexa and Zyrtec.
  73. "‘Pill-Splitting' Is a Patient-Safety Concern," National Association of Chain Drug Stores, Issue Brief, October 2004.
  74. James E. Polli, Sharon Kim and Brian R. Martin, "Weight Uniformity of Split Tablets Required by a Veterans Affairs Policy," Journal of Managed Care Pharmacy, Vol. 8, No. 5, 2003, pages 401-7.
  75. Randal S. Stafford and David C. Radley, "The Potential of Pill Splitting to Achieve Cost Savings," American Journal of Managed Care, Vol. 8, No. 8, August 2002, pages 706-12.
  76. Susan J. Landers, "11 Pills Score as Candidates for Splitting," American Medical News, September 23/30, 2002.
  77. "Bitter Pill: The Rising Prices of Prescription Drugs for Older Americans," Families USA, Publication No. 02-104, June 2002.
  78. William M. Welch, "VA Offers Medicines at Bargain Prices," USA Today, June 18, 2003.
  79. Aidan Hollis, "Closing the FDA's Orange Book," Regulation, Winter 2001.
  80. The average cost for generic prescriptions was $12.82 in 1993, compared to $35.28 for branded medications.  By 2003 this had risen to $30.58 and $83.66 respectively.  See "Retail Prescription Prices for Generic Drugs," National Association of Chain Drug Stores, Issue Brief, October 2004.  Also see "Industry Facts-at-a-Glance," National Association of Chain Drug Stores.  Available at http://www.nacds.org/wmspage.cfm?parm1=507#retail.  Accessed June 6, 2006.
  81. James Frederick, "Stars Align for Generic Drug Industry - Special Report: Generic Drugs," Drug Store News, February 16, 2004.
  82. Fred Gebhart, "Major Drugs Lose Patent Protection in 2006," Drug Topics, Generic Supplement, April 3, 2006.
  83. Ibid.
  84. Leila Abboud, "Bush Acts to Speed Generics to Market," Wall Street Journal, June 12, 2003, page A3.
  85. The law became effective August 19, 2003.  See Joel B. Finkelstein, "Feds Fire on Patent Law that Delays Generics," American Medical News, June 30, 2003. 
  86. If Zocor is approved for sale in generic form, the price will likely fall 80 percent by early to mid 2007.  However, the FDA has a backlog of about 800 drugs awaiting generic approval.  About 93 percent of generic applications fail on the first review whereas 59 percent fail their second review.  See Tony Pugh (Knight-Ridder), "Generic Drug's Path to Retail Market Often Long and Contentious," Kansas City Star, April 27, 2006.
  87. Paula Moyer, "Huge Fight Expected When Statin Patents Expire," Drug Topics, Supplement, August 8, 2005.
  88. Thomas Ginsberg, "A Shake-Up beyond Merck, Zocor's Patent Protection Ends," Philadelphia Inquirer, June 18, 2006, page E01.
  89. The patent on Pravachol is also set to expire in 2006.  See "The Statin Drugs," Consumer Reports Best Buy Drugs, January 2006.  Available at http://www.crbestbuydrugs.org/PDFs/StatinAnalysis.pdf.  Accessed June 20, 2006.
  90. Steve Lohr, "Smart Care via a Mouse, but What Will It Cost?" New York Times, August 20, 2006.
  91. "Fact Sheet: The Use of Over-the-Counter Medicines," National Council on Patient Information and Education, January 2002.
  92. Harris Interactive, "Attitudes and Beliefs about the Use of Over-the-Counter Medicines: A Dose of Reality," National Council on Patient Information and Education (NCPIE), January 2002.
  93. Ipsos, "Doctor Recommendations of Over-The-Counter Drugs Boost Consumer Loyalty," PharmTrends, September 23, 2002.
  94. Drugs such as marijuana, cocaine and heroin were illegal to sell at all.  However, the class of drugs known as prescription drugs did not exist.  Patients relied on drugstores to advise them on the appropriate drugs to purchase.  Physicians also sold drugs directly to patients.
  95. Durham-Humphrey Amendment created a class of drugs that required medical supervision and restricted sales to persons who had a prescription from a medical practitioner.  See "Milestones in U.S. Food and Drug Law History," U.S. Food and Drug Administration, FDA Backgrounder, May 3, 1999.
  96. "The Economic and Public Health Value of Self-Medication," Association of the European Self-Medication Industry (AESGP), June 2004.  Available at http://www.aesgp.be/ephv/2004study.pdf.  Accessed June 14, 2006.
  97. This section is based on Paul Kittinger and Devon Herrick, "Patient Power: Over-the-Counter Drugs," National Center for Policy Analysis, Brief Analysis No. 524, August 22, 2005.
  98. Joshua P. Cohen, Cherie Paquette and Catherine P. Cairns, "Switching Prescription Drugs to Over the Counter," British Medical Journal, Vol. 330, No. 7481, January 1, 2005, pages 39-41.
  99. "Ingredients and Dosages Transferred from Rx-to-OTC Status (or New OTC Approvals) by the Food and Drug Administration since 1975," Consumer Healthcare Products Association, January 26, 2006.  Available at  http://www.chpa-info.org/NR/rdonlyres/E33F414C-24FE-4F34-B6FD-149D16DCE2FA/0/switch_list.pdf.  Accessed June 6, 2006.
  100. Sandra Levy, "Should Orlistat, Triptans Go OTC? R.Ph.s Speak Out," Drug Topics, February 6, 2006.
  101. Gaye Perry and Peter Mansell, "Rx-to-OTC Switching: The Way Forward for the Global Pharmaceutical Industry?" Urch Publishing Ltd., research report, September 2000.
  102. Holly M. Spencer, "The Rx-to-OTC Switch of Claritin, Allegra, and Zyrtec: An Unprecedented FDA Response to Petitioners and the Protection of Public Health," American University Law Review, pages 999-1,050.
  103. The prices of H2 antagonists fell by two-thirds after they were switched to OTC status.  See Gail D. Newton et al., "New OTC Drugs and Devices 2001: A Selective Review," Journal of the American Pharmaceutical Association, Vol. 42, No. 2, 2002, pages 267-77.
  104. Prescription sales of Claritin totaled $3.2 billion in 2001. Paul N. Jaber, Jr., "Schering-Plough's Trap," The Motley Fool, Commentary, October 7, 2003.  Available at http://www.fool.com/news/commentary/2003/commentary031007pnj.htm.  Accessed October 30, 2006.
  105. David Vaczek, "Top 200 Prescription Drugs of 2003," Pharmacy Times, undated, July 2004. Available at http://www.pharmacytimes.com/article.cfm?ID=1314.  Accessed August 21, 2004.  Due both to tightening of health plan requirements and the movement of Claritin to the OTC market, sales of nonsedating antihistamines fell 22 percent from July 2003 to June 2004.  See Jane Erikson, "Allergy Drug Copays Rising," Arizona Daily Star, August 18, 2004. Available at http://www.dailystar.com/dailystar/relatedarticles/34243.php.
  106. Price surveyed August 2002.
  107. Sixty Claritin tablets cost $31.39 at Costco.com.  Prices surveyed June 6, 2006.  The price for Loratadine (10mg) was based on buying two bottles of 150 tablets packaged together.  Prices were surveyed on May 24, 2006, at Sam's Club (Greenville at Park Lane), Dallas, Texas.
  108. Price surveyed May 2003.
  109. Price surveyed November 2006.
  110. Kenneth I. Kaitin (editor), "Switching Drugs from Prescription to OTC Status on Rise in U.S. and EU," Tufts Center for the Study of Drug Development, Impact Report, Vol. 5, No. 5, September/October 2003.  Also see "Legal Classification Status of Selected Ingredients Worldwide," AESGP (European Self-Medication Industry), March 31, 2006. Available at http://www.aesgp.be/Ingredients/WorldTable.pdf.  Accessed June 6, 2006.
  111. This section is based on Devon Herrick, "Patient Power: Access to Drugs," National Center for Policy Analysis, Brief Analysis No. 500, February 10, 2005.
  112. Michelle Roberts, "Statin-Fortified Drinking Water?" BBC News, August 1, 2004.
  113. Zosia Kmietowicz, "Statins are the New Aspirin, Oxford Researchers Say," British Medical Journal, News, Vol. 323, No. 7322, November 17, 2001.
  114. "Pharmacists to Sell Heart Drugs," BBC News, May 12, 2004.
  115. Jerry Avorn, "FDA Standards - Good Enough for Government Work?" New England Journal of Medicine, Vol. 353, No. 10, September 8, 2005, pages 969-972.
  116. In some cases a newer drug is considered an improvement not because it works better, but because its side effects are better tolerated.  An example of this is first-generation (sedating) antihistamines and second-generation (non-sedating) antihistamines.
  117. Peter J. Neumann, Allison B. Rosen and Milton C. Weinstein, "Medicare and Cost-Effectiveness Analysis," New England Journal of Medicine, Vol. 353, No. 14, October 6, 2005, pages 1516-22.
  118. Steven D. Findlay, "Bringing the DERP to Consumers: ‘Consumer Reports Best Buy Drugs,'" Health Affairs, Web Exclusive W283, June 6, 2006.  Available at http://content.healthaffairs.org/cgi/reprint/hlthaff.25.w283v1. Accessed June 6, 2006. 
  119. See Consumer Reports Best Buy Drugs.  Available at http://www.crbestbuydrugs.org.  Accessed June 6, 2006.
  120. Web site AskAPatient.com.
  121. Bill Hogan, "The Pharmacist Who Says No to Drugs," AARP Bulletin Online, September 2004.  Accessed September 8, 2004. Available: www.aarp.org/bulletin/prescription/Articles/a2004-08-26-pharmacist.html.
  122. Margie Rauch Goulding, "Inappropriate Medication Prescribing for Elderly Ambulatory Patients," Archives of Internal Medicine, Vol. 164, No. 3, February 9, 2004, pages 305-312.
  123. Lesley H. Curtis et al., "Inappropriate Prescribing for Elderly Americans in a Large Outpatient Population," Archives of Internal Medicine, Vol. 164, No. 15, August 9/23, 2004, pages 1,621-25.
  124. Ibid.  Panel members defined drugs to be inappropriate if risk of adverse reactions outweighed potential benefits.  Also see "1 in 12 Drugs Inappropriately Prescribed to Elderly," Healthfacts, March 2004.   
  125. Spyros Andreopoulos, "A Nation of Hypochondriacs?" San Francisco Chronicle, November 29, 2004.
  126. "Men with ED Achieve Sexual Satisfaction with Viagra, and Better Relationships," MedicalNewsToday.com, December 8, 2004.
  127. On the Web site AskaPatient.com, patients rated Propecia 2.6 out of 5 for effectiveness.
  128. Jawahar L. Mehta et al., "Comparison of Mortality Rates in Statin Users versus Nonstatin Users in a United States Veteran Population," American Journal of Cardiology, Vol. 98, No. 7, October 1, 2006, pages 923-28.
  129. "Everything You Need to Know about Statin Drugs - Almost," Healthfacts, November 2003. 
  130. PREMIER Collaborative Research Group, "Effects of Comprehensive Lifestyle Modification on Blood Pressure Control," Journal of the American Medical Association, Vol. 289, No. 16, April 2003, pages 2,083-93.
  131. Rena R. Wing et al., "Behavioral Science Research in Diabetes: Lifestyle Changes Related to Obesity, Eating Behavior, and Physical Activity," Diabetes Care, January 2001.
  132. Marian McDonagh and Susan Carson, "Drug Class Review on Proton Pump Inhibitors," Oregon Evidence-based Practice Center, Oregon Health & Science University, July 2006. 
  133. "Diuretics Proved to be Superior to Other, More Expensive Anti-Hypertensive Drugs," Healthfacts, January 2003. 
  134. Philip B. Gorelick, "Aspirin and Ticlopidine for Prevention of Recurrent Stroke in Black Patients," Journal of the American Medical Association, June 11, 2003, pages 2,947-57.
  135. Price comparisons were obtained from DestinationRX.com on October 27, 2006.  A patient taking two (250mg) tablets per day purchased in quantity (such as 100 tablets) could spend at little as $23.84 at RxUSA.com compared to $62.20 per month at AARP. 
  136. When combination therapy was taken at the first sign of a migraine headache.  See Patrice G.W. Norton, "OTC Product Beats Sumatriptan for Early Migraine: Study of 171 Patients - Clinical Rounds," OB/GYN News, September 15, 2003.
  137. Ibid.
  138. Gastroenterologists say most patients with GERD should first try H2-receptor antagonists.  See Marian McDonagh and Susan Carson, "Drug Class Review on Proton Pump Inhibitors," Oregon Evidence-based Practice Center, Oregon Health & Science University, July 2006.
  139. Bextra and Celebrex have been withdrawn, leaving Celebrex as the only available Cox-2 inhibitor.  Not all experts agree that Cox-2 inhibitors are more risky than older nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen and Naproxen. For instance, John Calfee, a scholar with the American Enterprise Institute, points out that between 10,000 and 20,000 people die annually of complications from taking older NSAIDS.  See John Calfee, "The Vioxx Fallout," American Enterprise Institute for Public Policy Research, Health Policy Outlook, September/October 2005.
  140. Emily R. Cox et al., "Prescribing COX-2s for Patients New to Cyclo-Oxygenase Inhibition Therapy," American Journal of Managed Care, Vol. 9, No. 11, November 2003, pages 735-42.  For a layman's discussion see "A New Study from Express Scripts Inc. Indicates that Patients Are Being Prescribed Expensive Cox-2 Inhibitor Drugs Even When They Have No Increased Risk for Gastrointestinal Events," Drug Cost Management Report, November 21, 2003.   
  141. Theresa Agovino (Associated Press), "Study: Pricey Drugs Overprescribed Oft-Hyped Pain Relievers Often Found Unnecessary, Raise Health Plan Costs," Detroit News, June 4, 2002.
  142. "Over Half of COX-2 Patients Take Aspirin, Possibly Negating the COX-2 GI Benefits," Medi-Lexicon (pharma-lexicon.com), June 15, 2004.  For a discussion see Emily R. Cox, Mark Frisse, Andrew Behm and Kathleen A. Fairman, "Over-the-Counter Pain Reliever and Aspirin Use Within a Sample of Long-Term Cyclo-Oxygenase 2 Users," Archives of Internal Medicine, Vol. 164, No. 11, June 14, 2004. 
  143. For a comparison of pain relievers to treat arthritis, see Mitchel L. Zoler and Winnie Anne Imperio, "Drug Update: NSAIDs for Rheumatoid Arthritis," OB/GYN News, June 1, 2000.
  144. Emily R. Cox, Brenda R. Motheral and Doug Mager, "Verification of a Decision Analytic Model Assumption Using Real-World Practice Data: Implications for the Cost Effectiveness of Cyclo-Oxygenase 2 Inhibitors (COX-2s),"American Journal of Managed Care, Vol. 9, No. 12, December 2003, pages 785-94. 
  145. Vioxx was pulled off the market by its maker Merck & Co in September 2004, and Bextra was withdrawn from the market by Pfizer in April 2005.
  146. Francis K.L. Chan et al., "Celecoxib versus Diclofenac and Omeprazole in Reducing the Risk of Recurrent Ulcer Bleeding in Patients with Arthritis," New England Journal of Medicine, Vol. 347, No. 26, December 26, 2002, pages 2,104-10; M. B. Kimmey and A. Lanas, "Appropriate Use of Proton Pump Inhibitors with Traditional Nonsteroidal Anti-inflammatory Drugs and COX-2 Selective Inhibitors," Alimentary Pharmacology & Therapeutics, Vol. 19, No. 1, February 2004, pages 60-65.  Also see American College of Gastroenterology 68th Annual Scientific Meeting and Postgraduate Course, reviewed in Charlene Laino, "Proton Pump Inhibitor May Help Prevent Ulcers in Chronic NSAID Users," Medscape Medical News, October 15, 2003.
  147. On AskAPatient.com, 837 rated antihistamines as average score of 2.6 out of a possible 5 points.  By comparison, 59 people voting rated Viagra an average of 4.2.
  148. Stephen Hall, "The Claritin Effect: Prescription for Profit," New York Times Magazine, March 11, 2001.
  149. Ibid.
  150. Ibid. According to a New York Times Magazine exposé, the FDA medical officer assigned to review Loratadine's efficacy, Sherwin Straus thought the 10mg dose was about four times too low.  He thought a 40mg dose was the "minimally effective" dose to relieve allergy symptoms.
  151. The FDA also approved a 10mg dose that incorporated pseudoephedrine as Claritin-D.
  152. A. Pineyro-Lopez et al., "Bioavailability of Two Oral Formulations of Loratadine 20mg with Concomitant Ketoconazole: An Open-Label, Randomized, Two-Period Crossover Comparison in Healthy Mexican Adult Volunteers," Clinical Therapeutics, Vol. 28, No. 1, January 2006, pages 110-115.  Also see "Generic Version of Allergy Drug Allegra (fexofenadine) Now Available," Consumer Reports Best Buy Drugs, 2005.
  153. Betsy Bates, "Chronic Urticaria: Boost Antihistamine Dosage," Family Practice News, March 1, 2001.
  154. Aventis claimed in legal proceedings that not all of the numerous patents pertaining to Allegra had expired.  In 2004 and 2005, courts invalidated four patents still claimed by Aventis.  The remaining patent pertained to extended release, which is not required to produce it in generic form.  See Calvert D. Crary, "Aventis' Patent Litigation," Litigation Notes, C. D. Crary & Co., September 21, 2005.  Also see Michelle Whelan, "Generic Pharma Battles for Allegra Rights," Pharmacy Times, October 2005.
  155. "FDA Approves Generic Allegra Capsules - Litigation Continues," Rx Update, August 2005.
  156. Prices surveyed at Drugstore.com November 2006.
  157. Aaron Smith, "New Profit Twist for Drug Makers," CNN/Money, May 11, 2005.
  158. "Generic Competition to 2009: The Impact of Patent Expiries on Sales of Major Drugs," Urch Publishing Limited, Strategic Report, October 2005.
  159. Inhaled corticosteroid nasal spray in the most effective way to treat symptoms of allergic rhinitis including nasal congestion, runny nose and sneezing.  William Berger, Allergies and Asthma for Dummies (New York: Hungry Minds Inc., 2000)
  160. "FDA Approves First Generic Version of Flonase," MedicalNewsToday.com, February 23, 2006.
  161. In this case the difference in shipping cost between Costco.com and RxUSA.com would likely remove any cost benefit of pill splitting.
  162. "Canadian Pharmacies," Drugstore News, December 16, 2002.
  163. David Gratzer and Neil Seeman, "Granny Goes North: The Truth about Canada and Prescription Drugs," National Review, May 22, 2000.
  164. Stephen Majors (Associated Press), "Customs to Stop Seizing Prescription Drug Shipments from Canada," South Florida Sun-Sentinel, October 3, 2006.
  165. Bernard S. Bloom and Ronald C. Iannacone, "Internet Availability of Prescription Pharmaceuticals to the Public," Annals of Internal Medicine, December 7, 1999, pages 830-33.
  166. Ibid.
  167. Ibid.
  168. Sample of 45 Internet pharmacy Web sites claiming to be Canadian.  See "An Analysis of Terrorist Threats to America's Medicine Supply," GlobalOptions Inc., May 22, 2003. 
  169. "Mexican Drugs Shipped to U.S. via Canada, say Consumers," Scrip: World Pharmaceutical News, No 2942, April 9, 2004, page 17.
  170. Marv Shepherd, "Statement on Importation of Prescription Drugs Submitted by the Academy of Managed Care Pharmacy to the United States Department of Health and Human Services Task Force on Drug Importation," May 14, 2004.
  171. Michael A. Veronin and Bi-Botti C. Youan, "Magic Bullet Gone Astray: Medications and the Internet," Science, Vol. 305, July 23, 2004, page 481.
  172. Donna Young, "FDA Clarifies Importation Law as Internet Pharmacies Proliferate," American Journal of Health-System Pharmacy, Vol. 60, No. 8, May 2003, page 729.
  173. See, for example, William K. Hubbard, Senior Associate Commissioner for Policy, Planning and Legislation, Food and Drug Administration, "Continuing Concerns over Imported Pharmaceuticals," Testimony before the Subcommittee on Oversight and Investigations, U.S. House Committee on Energy and Commerce, June 7, 2001.
  174. Michael F. Conlan, "How Safe Is the Drug Supply?" Drug Topics, October 15, 2001.
  175. Paul M. Rudolf and Ilisa B.G. Bernstein, "Counterfeit Drugs," New England Journal of Medicine, Vol. 350, No. 14, April 1, 2004, pages 1384 - 86.
  176. "Counterfeit Medicines," World Health Organization, Fact Sheet No. 275, February 2006.
  177. Paul M. Rudolf and Ilisa B.G. Bernstein, "Counterfeit Drugs," New England Journal of Medicine, Vol. 350, No. 14, April 1, 2004, pages 1,384 - 86.  Also see U.S. Food and Drug Administration, "FDA Takes Action Against Foreign Websites Selling Counterfeit Contraceptive Patches," FDA News, U.S. Food and Drug Administration, U.S. Department of Health and Human Services, February 12, 2004.
  178. Tracy Wheeler "Web May Not Be Rx for Your Drug Needs," Akron (Ohio) Beacon Journal, July 06, 2004.
  179. Ibid.
  180. Bette Hileman, "Counterfeit Drugs," Chemical & Engineering News, Vol. 81, No. 45, November 10, 2003.
  181. "Drug Expenditure in Canada 1985 to 2005" Canadian Institute for Health Information, May 10, 2006.
  182. Julie Appleby, "Report Attempts to Show Impact of Cross-Border Access," USA Today, May 17, 2004.
  183. For a list of discount programs for specific medications, see Needymeds.com.  Also, www.helpingpatients.org can help patients determine whether or not they qualify for various programs.  Accessibility to both Web sites verified July 12, 2004. 
  184. Information obtained from pparx.com and TogetherRXaccess.com.  Accessed October 31, 2006.
  185. Richard Cauchi (NCSL Health Care Program), "State Pharmaceutical Assistance Programs," National Conference of State Legislators, July 2004; available at http://www.ncsl.org/programs/health/drugaid.htm.

Appendix A-1 Prescription Sinus Allergy MedicationsAppendix A-2 - Over-the-Counter Sinus Allergy MedicationsAppendix B-1 - Prescription Heartburn MedicationsAppendix B-2 - Over-the-Counter Ulcer MedicationsAppendix C - Cardiovascular MedicationsAppendix D - Anti-Anxiety Medications


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