Variation in the Cost of Generic Topical Corticosteroids

Home , Hydrocortisone acetate, Triamcinolone acetonide, Triamcinolone furetonide

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RESEARCH LETTER by the pharmacy or patient.3 Descriptive statistics were performed using SAS, version 9.3 (SAS Institute). Prices were ad- Variation in the Cost of Generic Topical justed for inflation and are reported in 2013 US dollars.4 The Corticosteroids Penn State Institutional Review Board exempted this study Prescription medications accounted for $307 billion in the from review. Analysis was performed March 5 to June 2, 2015. United States in 2010, or about 12% of all US health care spending. Prescribing generic rather than brand-name medica- Results | The cost of topical corticosteroids varied across po- tions, including topical medications, has been encouraged as tencies, class (potency), and by branded generic or generic a way to curb spending on prescription medications. In fact, product. Claims for branded generic products were less fre- the growth of spending on prescription medication has de- quent and had a higher copayment and AWP. Table 1 shows the creased in association with increased use of generic drugs.1 mean copayment for topical corticosteroids. There are note- However, practitioners and patients can be frustrated by the worthy differences among generic topical corticosteroids in the affordability of even older generic medications.2 This para- same class; for example, the mean cost of triamcinolone ace- doxical situation came to light with the shortage, and subse- tonide, 0.01%, was 30% to 40% lower than other mid- quent increased cost, of doxycycline hydrochloride in 2013. Re- potency medications when dispensed as a 15-g or 30-g tube. cently, we had many patients experience a high cost for topical There were also important differences in the cost per gram for clobetasol propionate; we undertook this study to investi- different size tubes of the same medication (Table 1), such as gate the variation in costs of generic topical corticosteroids of triamcinolone acetonide, 0.01%, which was $0.24 per gram as various potencies. a 15-g tube vs $0.02 per gram when dispensed in a 454-g jar. Also, branded generic products had copayments approxi- Methods | We investigated the unit cost for topical corticoste- mately 3 to 5 times higher than a generic product with the same roids of multiple potencies and unit size by retrospectively ana- ingredient and unit size. lyzing the Truven Health MarketScan Commercial Claims and As expected, the mean AWP was higher than the mean co- Encounters Database, which contains health insurance claims payment for all corticosteroids and sizes (Table 2). Again, there paid by approximately 100 payers for more than 120 million were cost differences among topical corticosteroids by po- individuals in the United States. Paid prescription claims for tency or unit size. For instance, 1 pound of triamcinolone ace- topical corticosteroids during the study period (January 1, tonide, 0.01% ($40.73 for a 454-g jar), and betamethasone val- 2008, through December 31, 2013) were identified. The co- erate, 0.1% ($324.40 for ten 45-g tubes), have nearly a 10-fold payment and average wholesale price (AWP) were extracted. difference in cost despite similar potency. Also, fluocinonide The copayment reflects the patient’s out-of-pocket cost; and acetonide, 0.05%, was approximately half the cost of the simi- though the AWP is a frequently cited conventional variable, it larly potent clobetasol propionate, 0.05%, cream ($23.20 vs is less practical because it is often higher than the price paid $42.07 per 30 g).

Table 1. Comparison of the Mean Copayment and Price per Gram From January 1, 2008, Through December 31, 2013, for Topical Corticosteroids

Copayment (Price per Gram), $a Branded Generic Corticosteroid Class, Potency or Generic 15 g 30 g 45 g 60 g 80 g 454 g Branded generic ND 31.44 21.88 32.55 (0.54) NA NA Clobetasol propionate, 0.05% 1, Very high Generic 5.86 (0.39) 6.78 7.31 7.42 (0.12) ND ND Branded generic ND ND NA ND NA NA Fluocinonide acetonide, 0.05% 2, Very high Generic 5.29 (0.35) 5.91 ND 6.61 (0.11) ND ND Branded generic ND ND NA NA ND ND Triamcinolone acetonide, 0.01% 4, Medium Generic 3.58 (0.24) 5.03 ND ND 5.60 7.71 (0.02) Branded generic ND ND ND NA NA NA Betamethasone valerate, 0.1% 4, Medium Generic 6.16 (0.41) 7.00 7.11 ND ND ND Branded generic 16.96 (1.13) NA 20.77 NA NA NA Mometasone furoate, 0.1% 4, Medium Generic 6.20 (0.41) ND 7.31 ND ND ND Branded generic ND 8.00 NA 15.92 (0.27) NA NA Hydrocortisone acetate, 1% 7, Very low Generic 2.26 (0.15) 5.46 ND 8.74 (0.15) ND ND Abbreviations: NA, not available in this size; ND, no data for this size and a Some copayments show price per gram because these calculations were medication. performed for 2 unit sizes that were available for most of the medications.

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Table 2. Comparison of the Mean Average Wholesale Price and Price per Gram From January 1, 2008, Through December 31, 2013, for Topical Corticosteroids

Average Wholesale Price (Price per Gram), $a Corticosteroid Class, Potency Branded Generic or Generic 15 g 30 g 45 g 60 g 80 g 454 g Branded generic ND 176.42 229.64 318.89 (5.31) NA NA Clobetasol propionate, 0.05% 1, Very high Generic 28.62 (1.91) 42.07 62.04 74.83 (1.25) ND ND Branded generic ND ND NA ND NA NA Fluocinonide acetonide, 0.05% 2, Very high Generic 15.84 (1.06) 23.20 ND 32.93 (0.55) ND ND Branded generic ND ND NA NA ND ND Triamcinolone acetonide, 0.01% 4, Medium Generic 7.34 (0.49) 12.03 ND ND 13.34 40.73 (0.09) Branded generic ND ND ND NA NA NA Betamethasone valerate, 0.1% 4, Medium Generic 15.33 (1.02) 30.75 32.44 ND ND ND Branded generic 46.07 (3.07) NA 88.79 NA NA NA Mometasone furoate, 0.1% 4, Medium Generic 26.90 (1.79) ND 52.21 ND ND ND Branded generic ND 148.93 NA 297.86 (4.96) NA NA Hydrocortisone acetate, 1% 7, Very low Generic 2.61 (0.17) 27.97 ND 17.89 (0.30) ND ND Abbreviations: NA, not available in this size; ND, no data for this size and medication. a Some average wholesale prices show price per gram because these calculations were performed for 2 unit sizes that were available for most of the medications.

Discussion | Successfully managing dermatologic conditions re- Administrative, technical, or material support:Foulke,Kirby. quires health care professionals to not only develop a diagno- Study supervision:Foulke,Kirby. sis and treatment plan but also consider the patient’s finan- Conflict of Interest Disclosures: None reported. cial burden. The mean retail price of a generic drug is 75% lower Additional Contributions: Douglas Leslie, PhD, Department of Public Health Sciences, Penn State, assisted with the statistical analysis. He was not than its brand-name equivalent, and increasing generic drug compensated for his contribution. use saved approximately $1 trillion in health care costs from 1. Copeland R, Black K, Pachter L, Svoboda R. Drug pricing: research on savings 3 1999 through 2010. However, generic medications are not from generic drug use. January 31, 2012. http://www.gao.gov/assets/590 similarly priced, as this investigation shows. Furthermore, the /588064.pdf. Accessed May 2, 2015. mean AWP and copayment for generic topical corticosteroids 2. Alpern JD, Stauffer WM, Kesselheim AS. High-cost generic drugs— are not proportional to potency and larger units are more cost implications for patients and policymakers. N Engl J Med. 2014;371(20):1859-1862. effective. There are opportunities to reduce costs by prescrib- 3. Office of the Inspector General, Department of Health and Human Services. ing larger units rather than repeatedly refilling smaller tubes. Medicaid drug price comparison: average sales price to average wholesale price. https://oig.hhs.gov/oei/reports/oei-03-05-00200.pdf. Accessed March 7, 2015. The limitations of this investigation include difficulty gener- 4. Bureau of Labor Statistics, US Department of Labor. Consumer Price Index. alizing the findings to specific situations, lack of patient out- Updated May 2015. http://www.bls.gov/cpi/. Accessed March 3, 2015. comes, and not controlling for differences in drug vehicles. Health care professionals may preserve high-quality patient Recent Changes in the Prevalence of and Factors care while reducing cost for the patient by being aware of the Associated With Frequency of Indoor Tanning differences in generic medications. Among US Adults Reducing indoor tanning is a Healthy People 2020 objective and Alexander Skojec, BS an important strategy for preventing skin cancer.1 We examined Galen Foulke, MD changes in the prevalence and frequency of indoor tanning fac- Joslyn S. Kirby, MD, MS tors associated with frequency of indoor tanning among US adults.

Author Affiliations: Penn State Hershey College of Medicine, Hershey, Pennsylvania (Skojec); Department of Dermatology, Penn State Milton S. Methods | We analyzed data collected from the 2010 and 2013 Hershey Medical Center, Hershey, Pennsylvania (Foulke, Kirby). National Health Interview Survey, a nationally representa- Accepted for Publication: June 15, 2015. tive sample of the US civilian, noninstitutionalized popula- Corresponding Author: Joslyn S. Kirby, MD, MS, Department of Dermatology, tion 18 years or older (N = 59 145). The data were collected from Penn State Milton S. Hershey Medical Center, 500 University Ave, Mailcode HU January 1st to December 31st for each survey year. The final 14, Hershey, PA 17033 ([email protected]). response rates were 60.8% in 2010 and 61.2% in 2013.2 Our Published Online: August 19, 2015. doi:10.1001/jamadermatol.2015.2394. analysis was exempted from Centers for Disease Control and Author Contributions: Dr Foulke and Mr Skojec had full access to all the data in Prevention Institutional Review Board approval. Indoor tan- the study and take responsibility for the integrity of the data and the accuracy of the data analysis. ning was defined as using an indoor tanning device 1 or more Study concept and design: All authors. times during the 12 months before each survey. We calcu- Acquisition, analysis, or interpretation of data: All authors. lated the prevalence of indoor tanning in 2010 and 2013 and Drafting of the manuscript: All authors. used log-linear regression to examine the factors associated Critical revision of the manuscript for important intellectual content: Foulke, Kirby. with indoor tanning frequency among indoor tanners using Statistical analysis:Skojec. pooled data from both years. Differences between categories

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