The Price of ED: Annual Out of Pocket Cost Disparities of Erectile Dysfunction Medications

The Price of ED: Annual Out of Pocket Cost Disparities of Erectile Dysfunction Medications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Price of ED: Annual Out of Pocket Cost Disparities of Erectile Dysfunction Medications Aaron Gurayah, MANISH KUCHAKULLA, Samantha Thorogood1, Robert Fisch, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5257265/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Our objective was to understand the out-of-pocket (OOP) annual costs for PDE5-I to treat erectile dysfunction (ED) through traditional Medicare Part D drug coverage programs and other popular discount programs. We collected data on annual OOP costs for ED medications from four different sources: Medicare Part D, GoodRx, Mark Cuban Cost Plus Drug Company (MCCPDC), and Amazon Pharmacy. We compared the cost of lowest and highest routinely prescribed dosage of medications for Sildenafil, Tadalafil, and Vardenafil. We examined the cost of PDE5-I under Medicare Part D at 1) hospital retail pharmacies (using twelve zip codes encompassing areas with comprehensive urologic oncology centers) and 2) three most prevalent commercial retail pharmacies (CVS, Walgreens, and Walmart). These findings were compared to discount platforms GoodRx (via CVS, Walgreens, and Walmart), MCCPDC, and Amazon Pharmacy using R (V4.1.1). For Sildenafil 20mg, the Part D annual OOP costs including hospitals and retail pharmacies were comparable ranging from $1 024-$1 098. The cost at discount platforms was cheaper, ranging from $82-$275. For Sildenafil 100mg, the hospital-based pharmacies had a median price of $1 446, whereas retail pharmacies under Part D ranged from $22 528-$22 542. Discount platforms were preferred at $89-$324. For Tadalafil 2.5mg, the Part D groups ranged from $4 721-$4 759. The cost of this drug via discount platforms was much lower, ranging from $82-$312. For Tadalafil 20mg, the cost via Part D ranged from $25 210-$25 235. The discount platforms were reported to have lower costs ranging from $103-$496. Vardenafil ranged from $19 015-$19 039 from Part D groups and $86-418 from discount platforms. For both sildenafil dosages and tadalafil dosages, MCCPDC was the most affordable option. There are significant cost-savings when utilizing drug discount platforms. These options should be presented to patients to help improve accessibility and compliance to medications for ED. Health sciences/Health care/Quality of life Health sciences/Diseases/Reproductive disorders/Sexual dysfunction Erectile Dysfunction PDE-5 Inhibitors Discount Pharmacy Medicare Figures Figure 1 Introduction Erectile dysfunction (ED) is newly diagnosed in over 10 million American men every year and substantially affects intimate relationships, quality of life, and self-esteem ( 1 ). The prevalence of ED amongst men in the United States is estimated to be as high as 52% with older men more likely to experience ED ( 2 ). Furthermore, recent trends with online men’s health platforms have indicated that this number is likely significantly under-estimated ( 3 ). Additionally, men who have been treated for prostate cancer are disproportionately impacted by ED with up to 85% of these men reporting difficulties with erections following their treatment ( 4 ). First-line therapy for ED generally involves the use of oral phosphodiesterase 5 inhibitors (PDE5-I) due to their ease of use, relatively minimal side effect profile, and efficacy ( 5 ). In addition to the treatment of ED, daily use of PDE5-I have demonstrated clinical benefit in prostate-cancer related sexual dysfunction, more commonly referred to as penile rehabilitation ( 6 ). Given the high efficacy of PDE5-I use in erectile dysfunction treatment due to all causes, including prostate cancer survivorship, it is a commonly prescribed treatment. However, cost has been frequently cited as a significant barrier to access of these treatments, often due to limited coverage by insurance ( 4 ). In fact, Medicare Part D, one of the largest insurers by covering prescription drugs for over 50 million Americans, does not provide any coverage for PDE5-I to treat ED, even in men who have been treated for prostate cancer ( 7 ). Lastly, coverage is limited even within commercial employee-based hospital plans with an estimate that more than 75% of plans do not have coverage for PDE5-I ( 8 ). Given the significant widespread lack of insurance coverage for PDE5-I, our goal was to 1) understand the patient annual out-of-pocket cost associated with plans, such as Medicare Part D, that do not cover PDE5-I and 2) evaluate how much patients can save by utilizing popular discount platforms. Since as early as 2010, discount pharmaceutical platforms such as GoodRx, Amazon Pharmacy, and Mark Cuban Cost Plus Drug Company (MCCPDC) have been founded, making previously unaffordable medications more financially accessible. These platforms have the potential to provide significant cost-savings to patients prescribed PDE5-I by providing these drugs at a significantly lower cost than conventional retail options which are not covered by insurance plans. To test this hypothesis, we compared the costs of common PDE5-I between conventional retail stores under Medicare Part D and discount platforms to determine the amount of savings that a patient could encounter. By understanding the cost differences, the findings this study can better guide patients and physicians to increase patient access to highly efficacious ED treatments. Materials and Methods Study Sample and Data Collection We collected data on annual out-of-pocket (OOP) costs for ED medications from four different sources: Medicare Part D, GoodRx, MCCPDC, and Amazon Pharmacy. We compared the cost of lowest and highest routinely prescribed dosage of medications based on 30 tablets-per-month usage for three medications (Sildenafil 20mg/100mg, Tadalafil 2.5mg/20mg, Vardenafil 10mg/20mg). Vardenafil 10mg and 20mg were comparable across platforms, and thus were combined into one group. The Medicare Part D Plan Finder ( www.medicare.gov/plan-compare ) provides estimates of annual OOP costs including premiums, deductibles, co-pays, and co-insurance. This tool was developed by the U.S. Centers for Medicare & Medicaid Services and is publicly available. For our study, we used this tool to identify Part D plans available for selection in 2024, highlighting OOP differences based on network status. Programs such as Medicaid, Supplemental Security Income, Medicare Savings Program, and Social Security Benefits were excluded for the purpose of this analysis. Given that Medicare Part D does not cover this drug, we utilized the costs estimated by their cost plan finder as a proxy for any insurance plan that excludes PDE5-I given that this is the retail cost at the pharmacy. We compared the cost of PDE5-I under Medicare part D at 1) hospital retail pharmacies (identified using twelve different zip codes encompassing areas with comprehensive urologic oncology centers) and 2) the three largest commercial retail pharmacies in the United States (CVS, Walgreens, and Walmart) to popular discount platforms GoodRx ( https://www.goodrx.com ), MCCPDC ( https://costplusdrugs.com ) and Amazon Pharmacy ( https://pharmacy.amazon.com ) ( 9 , 10 ). Thus, the four Medicare Part D subgroups consisted of 1) Hospital-based, 2) CVS, 3) Walgreens and 4) Walmart. The twelve ZIP codes included 55902 (Rochester, MN), 44195 (Cleveland, OH), 10065 (New York City, NY), 77030 (Houston, TX), 21287 (Baltimore, MD), 90095 (Los Angeles, CA), 60611 (Chicago, IL), 48109 (Ann Arbor, MI), 37232 (Nashville, TN), 85054 (Phoenix, AZ), 19104 (Philadelphia, PA), and 02115 (Boston, MA). The annual cost for each ED medication dosage was obtained. For Amazon Pharmacy, the maximum dosage for Tadalafil was 10mg, so two tablets per day were used to represent the 20mg dosage. We identified the GoodRx drug reduction cost for CVS, Walmart and Walgreens. Data for this project were collected during the week of April 15th, 2024. Statistical Analysis The median for the twelve zip codes Medicare Part D (hospital-based, CVS, Walgreens and Walmart), GoodRx CVS, GoodRx Walgreens, GoodRx Walmart, MCCPDC, and Amazon Pharmacy were calculated. These values are displayed in Table 1 . For visualization purposes, the median for all four Medicare Part D subgroups was obtained. Additionally, the median for the three GoodRx retail pharmacies was calculated. Statistical analyses and visualizations were conducted using R (V4.1.1) Table 1 Annual Costs of Erectile Dysfunction Medications based on platform Medicare Part D Discount Platforms Drug Hospital CVS Walgreens Walmart GoodRx CVS GoodRx Walgreens GoodRx Walmart MCCPDC Amazon Sildenafil 20mg $ 1 024 $ 1 054 $ 1 078 $ 1 098 $ 275 $ 251 $ 192 $ 82 $ 132 Sildenafil 100mg $ 1 446 $ 22 528 $ 22 542 $ 22 528 $ 324 $ 312 $ 225 $ 89 $ 182 Tadalafil 2.5mg $ 4 721 $ 4 759 $ 4 723 $ 4 740 $ 282 $ 312 $ 225 $ 82 $ 161 Tadalafil 20mg $ 25 210 $ 25 222 $ 25 235 $ 25 218 $ 311 $ 336 $ 249 $ 103 $ 496 Vardenafil 10/20mg $ 19 015 $ 19 027 $ 19 039 $ 19 023 $ 86 $ 418 $ 136 $ 200 $ 149 Results For Sildenafil 20mg, the Part D annual OOP costs including hospitals and retails pharmacies were comparable ranging from $ 1 024- $ 1 098 (Table 1 ). The annual OOP cost of discount platforms was cheaper, ranging from $ 82- $ 275. For Sildenafil 100mg, the hospital-based pharmacies had a median annual OOP cost of $ 1 446, whereas retail pharmacies under Part D ranged from $ 22 528- $ 22 542. Discount platforms for this drug were preferred at an annual OOP cost of $ 89- $ 324. For Tadalafil 2.5mg, the annual OOP cost in Part D groups ranged from $ 4 721- $ 4 759 as compared to the range of $ 82- $ 312 for discount platforms. For Tadalafil 20mg, the annual OOP cost via Part D ranged from $ 25 210- $ 25 235, whereas the discount platform cost ranged from $ 103- $ 496. Vardenafil (both 10 and 20mg) ranged from $ 19 015- $ 19 039 from Part D groups and $ 86–418 from discount platform. For both sildenafil dosages and tadalafil dosages, MCCPDC was the most affordable option. For both Vardenafil, GoodRx CVS was the cheapest option. We then combined the four-Part D subgroups as well as the three pharmacies analyzed with GoodRx discounts to directly compare these purchasing options. For the lowest prescribed dose of sildenafil (20mg) and tadalafil (2.5mg), the annual OOP cost to patients was $ 1 066 and $ 4 372. Under GoodRx, patients would incur an annual OOP fee of $ 251, and $ 282 resulting in an annual savings of $ 815 and $ 4 090 respectively. More drastic OOP costs were observed for sildenafil 100mg and tadalafil 20mg with Part D incurring a $ 22,528 and $ 25,220, respectively, compared to the $ 312 and $ 311 cost via GoodRx, patients would save $ 22 216 and $ 24 909 on these respective medications. We saw similar trends for the other discount pharmacies including Amazon and MCCPDC compared to Part D Medicare (Fig. 1 ). Discussion This study compares the annual costs of the most common ED medication used by patients across four platforms: Medicare Part D, GoodRx at select retail pharmacies, Mark Cuban Cost Plus, and Amazon Pharmacy. Consistently, across different medications and dosages, we observed that discount platforms were significantly cheaper options compared to Medicare Part D. The results suggest that discount pharmacies provide prescription drugs at prices that offer significant cost-savings for patients when compared to conventional retail stores under Medicare Part D. Our findings are consistent with prior studies. In a study by Schloegel et al., prices of twelve drugs commonly used to treat urologic conditions available on MCCPDC were compared to local retail pharmacies in Lexington, Kentucky. Their analysis suggested that MCCPDC offered savings for 9 of the 12 urological drugs available on the website which contribute to significant cost savings over the course of a patient’s lifetime ( 1 ). As in our study, MCCPDC has proven to be an effective tool for consistently low and transparent drug pricing for patients. In another study by Pockros et al., the variability of OOP costs for frequently prescribed medication for advanced prostate cancer on available Medicare Part D drug plans was analyzed. Depending on the specific plan chosen by the patient, potential cost savings were up to $ 2 512 for enzalutamide and $ 9 321 for abiraterone demonstrating the high variability of cost to patients in these drugs plans ( 9 ). Although Medicare Part D plans provide coverage for certain drugs, it fails to provide any assistance for patients needing coverage for medications to treat ED. This complicates drug purchasing for patients and can lead to undue financial burden and non-compliance. An advantage of this study is the direct comparison of costs of drugs to the patient. We anticipate that these findings will provide prescribers with a clearer understanding of the cost burden and insurance limitations associated with PDE5-I within the Medicare population. Additionally, this study aims to highlight the frequent exclusion of these medications from coverage plans, helping clinicians make more informed treatment decisions for their patients. Physicians are not always reliable sources for information regarding healthcare costs, leaving patients without proper guidance ( 11 ). One study surveying 371 primary care physicians and specialists found that only 21% of physicians were able to estimate out-of-pocket costs accurately enough to discuss financial trade-offs with their patients ( 12 ). Other studies have found that doctors consistently overestimate the cost of cheaper drugs but underestimate the cost of more expensive ones ( 13 ). The high out of pocket costs for certain prescription medications may be a significant barrier for patients seeking treatment ( 14 ). To address these previously identified challenges, this study provides concrete cost-saving data, giving providers specific pricing information to facilitate more informed discussions with patients. Medicare Part D Plan Finder, GoodRx, MCCPDC, and Amazon pharmacy have all been recognized as tools that provide patients with affordable prescription options. Per recommendations, patients should use the Medicare Part D Plan Finder annually to compare drug plans and visit GoodRx for urgent prescription refills. For recurring generic prescriptions, the MCCPDC is beneficial, while Amazon RxPass is ideal for those on three or more chronic medications ( 1 ). It is important to note that with the passage of the Inflation Reduction Act in 2022, Medicare Part D beneficiaries will see a significant benefit starting in 2025, with a $ 2,000 cap on out-of-pocket prescription drug costs ( 15 ). This change offers substantial financial relief, particularly for those managing multiple high-cost chronic medications. However, cost-saving platforms will continue to provide meaningful advantages for patients, especially those with fewer annual medication needs. Additionally, while our analysis uses national average pricing, it does not factor in the geographic variability in drug costs, which has been widely reported and may have a notable impact on specific patient populations ( 16 ). The consistent nationwide pricing offered by MCCPDC and Amazon Pharmacy further underscores how these platforms can provide patients with transparent, cost-effective options. One of the key strengths of this study is the broad generalizability of the data. The pricing estimates from Medicare Part D serve as proxy pricing for insurance plans that do not cover PDE5-I such as Medicaid and certain commercial health insurance plans. This is because Medicare Part D finder estimates the cost of the drugs at these pharmacies without insurance coverage given the exclusion of these drugs. As a result, any individual without coverage for PDE5-I would encounter similar OOP costs, including those with commercial insurance plans who are ineligible for Medicare. As previously discussed, it is estimated that up to 75% of commercial insurance plans do not cover PDE5-I ( 4 ). This makes our findings generalizable beyond the Medicare Part D population and can be used to estimate the impact to any individual without insurance coverage of these medications. This study offers valuable insights into the financial challenges faced by men with ED and prostate cancer survivors experiencing post-treatment ED. To our knowledge, this is the first study to compare these specific platforms directly as it relates to out-of-pocket cost without insurance coverage. This analysis highlights the considerable cost disparity between traditional retail drugstores under and discount platforms like GoodRx, MCCPDC, and Amazon Pharmacy which can provide significant savings. Insights from this analysis are helpful for healthcare providers to more informatively counsel patients to help ensure cost-effective access to ED medications. This study is not without limitations. Firstly, the cost comparisons are based on prescription prices at a single point in time, which may not account for fluctuations or changes in dynamic markets. Additionally, the analysis focused on a limited number of zip codes and retail pharmacies, which may not fully capture geographic variations in pricing and availability. The study also excluded certain financial assistance programs such as Medicaid, Supplemental Security Income, and Medicare Savings Programs, which could affect out-of-pocket costs for some patients. Furthermore, potential differences in medication quality and efficacy between online and retail pharmacy options were not considered. Future research should address these limitations by incorporating a broader range of data sources, patient demographics, and longitudinal cost analyses. In conclusion, patients being treated for ED with PDE5-I can encounter significant annual cost savings, on the magnitude of thousands of dollars per year, when utilizing discount platforms such as GoodRx, MCCPDC, or Amazon pharmacy when compared to costs under traditional coverage plans such as Medicare Part D. The lack of appropriate coverage of PDE5-I by traditional insurance plans can limit access to patients resulting in non-compliance or undue financial burden. The findings of these studies should be utilized when counseling patients. Healthcare providers should educate patients on these alternative platforms to increase access to essential medication and alleviate financial burdens for this common urologic condition. Declarations Data Availability Statement Data on annual out of pocket costs for erectile dysfunction medication was extracted from The Medicare Part D Plan Finder (www.medicare.gov/plan-compare). This tool was developed by the U.S. Centers for Medicare & Medicaid Services and is publicly available Acknowledgments We appreciate the U.S. Centers for Medicare & Medicaid Services for providing public access to Medicare Part D Plan Finder data Author Contribution Statement Gurayah : data curation, methodology, formal analysis, and writing - original draft, review, and editing; Kuchakulla : data curation, writing - original draft, review, and editing; Thorogood : writing - original draft, review, and editing; Fisch : writing - original draft, review, and editing; Davuluri : conceptualization, investigation, methodology, project administration, writing - review and editing Funding No external funding was required to complete this work. Ethics Approval This data contains no PHI so ethics approval was not warranted to conduct this research. Competing Interest The authors report no competing financial interests in relation to the work. 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Variation in drug prices at pharmacies: are prices higher in poorer areas? Health Serv Res. 2009;44(2 Pt 1):606–17. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5257265","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":367818841,"identity":"a93186bc-37eb-46fa-979f-1825e980a8ec","order_by":0,"name":"Aaron Gurayah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYJADNoYPIJKdFC2MM0AkMylamHlAFCEt/O1nHz4u+HU4n39G8rPHNr+2yfMxMzB++JiDW4vEmXRj45l9hy1n3EgzN87tu23YxszALDlzGx5rDqSxSfP2HDZguJFgJp3bc5sRqIWNmRePFvnzzyBa5G+kf5O27LltT1CLwQ2gLTw/DhsY3Mgxk2b4cTuRoBbDG8+YjXkb0g0Mz7wpk+xtuJ3cxszYjNcvcufTGB/z/LE2kDuevk3ix5/btvPbmw9++IjP+yDA2AYkBBKgDAbGBgLqQeAPEPMfgDJGwSgYBaNgFKABAO1TT2nQdhaBAAAAAElFTkSuQmCC","orcid":"","institution":"Weill Cornell Medicine","correspondingAuthor":true,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Gurayah","suffix":""},{"id":367818842,"identity":"1fb11eae-352f-4fbd-b1aa-8c9b6f0ce98c","order_by":1,"name":"MANISH KUCHAKULLA","email":"","orcid":"","institution":"CORNELL","correspondingAuthor":false,"prefix":"","firstName":"MANISH","middleName":"","lastName":"KUCHAKULLA","suffix":""},{"id":367818843,"identity":"3d1e77b6-0153-44d6-93ce-77778dd787a3","order_by":2,"name":"Samantha Thorogood1","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"","lastName":"Thorogood1","suffix":""},{"id":367818844,"identity":"ee975043-8b11-4fa8-9948-2032e1a04c2c","order_by":3,"name":"Robert Fisch","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Fisch","suffix":""},{"id":367818845,"identity":"cceda843-c175-4840-bf14-2f2363562303","order_by":4,"name":"Meenakshi Davuluri","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Meenakshi","middleName":"","lastName":"Davuluri","suffix":""}],"badges":[],"createdAt":"2024-10-14 01:40:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5257265/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5257265/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67357934,"identity":"c839a71a-b5dd-4bd2-b850-fe3f4da6120b","added_by":"auto","created_at":"2024-10-24 05:28:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":277450,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAnnual Costs of Erectile Dysfunction Medications based on platform.\u003c/strong\u003e The number listed above the Plan D bars represents the annual out of pocket cost for the respective drug.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5257265/v1/f2b6388926c03401e864c106.png"},{"id":69334682,"identity":"d18ecdd4-7c7f-44cc-9b49-ddf5ca3cacf2","added_by":"auto","created_at":"2024-11-19 09:49:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":672827,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5257265/v1/cad59e36-f7dc-49af-9ce1-7e77cd2ce8d1.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"The Price of ED: Annual Out of Pocket Cost Disparities of Erectile Dysfunction Medications","fulltext":[{"header":"Introduction","content":"\u003cp\u003eErectile dysfunction (ED) is newly diagnosed in over 10\u0026nbsp;million American men every year and substantially affects intimate relationships, quality of life, and self-esteem (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The prevalence of ED amongst men in the United States is estimated to be as high as 52% with older men more likely to experience ED (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Furthermore, recent trends with online men\u0026rsquo;s health platforms have indicated that this number is likely significantly under-estimated (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Additionally, men who have been treated for prostate cancer are disproportionately impacted by ED with up to 85% of these men reporting difficulties with erections following their treatment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFirst-line therapy for ED generally involves the use of oral phosphodiesterase 5 inhibitors (PDE5-I) due to their ease of use, relatively minimal side effect profile, and efficacy (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In addition to the treatment of ED, daily use of PDE5-I have demonstrated clinical benefit in prostate-cancer related sexual dysfunction, more commonly referred to as penile rehabilitation (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Given the high efficacy of PDE5-I use in erectile dysfunction treatment due to all causes, including prostate cancer survivorship, it is a commonly prescribed treatment. However, cost has been frequently cited as a significant barrier to access of these treatments, often due to limited coverage by insurance (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In fact, Medicare Part D, one of the largest insurers by covering prescription drugs for over 50\u0026nbsp;million Americans, does not provide any coverage for PDE5-I to treat ED, even in men who have been treated for prostate cancer (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Lastly, coverage is limited even within commercial employee-based hospital plans with an estimate that more than 75% of plans do not have coverage for PDE5-I (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the significant widespread lack of insurance coverage for PDE5-I, our goal was to 1) understand the patient annual out-of-pocket cost associated with plans, such as Medicare Part D, that do not cover PDE5-I and 2) evaluate how much patients can save by utilizing popular discount platforms. Since as early as 2010, discount pharmaceutical platforms such as GoodRx, Amazon Pharmacy, and Mark Cuban Cost Plus Drug Company (MCCPDC) have been founded, making previously unaffordable medications more financially accessible. These platforms have the potential to provide significant cost-savings to patients prescribed PDE5-I by providing these drugs at a significantly lower cost than conventional retail options which are not covered by insurance plans. To test this hypothesis, we compared the costs of common PDE5-I between conventional retail stores under Medicare Part D and discount platforms to determine the amount of savings that a patient could encounter. By understanding the cost differences, the findings this study can better guide patients and physicians to increase patient access to highly efficacious ED treatments.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Sample and Data Collection\u003c/h2\u003e\n \u003cp\u003eWe collected data on annual out-of-pocket (OOP) costs for ED medications from four different sources: Medicare Part D, GoodRx, MCCPDC, and Amazon Pharmacy. We compared the cost of lowest and highest routinely prescribed dosage of medications based on 30 tablets-per-month usage for three medications (Sildenafil 20mg/100mg, Tadalafil 2.5mg/20mg, Vardenafil 10mg/20mg). Vardenafil 10mg and 20mg were comparable across platforms, and thus were combined into one group.\u003c/p\u003e\n \u003cp\u003eThe Medicare Part D Plan Finder (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.medicare.gov/plan-compare\u003c/span\u003e\u003c/span\u003e) provides estimates of annual OOP costs including premiums, deductibles, co-pays, and co-insurance. This tool was developed by the U.S. Centers for Medicare \u0026amp; Medicaid Services and is publicly available. For our study, we used this tool to identify Part D plans available for selection in 2024, highlighting OOP differences based on network status. Programs such as Medicaid, Supplemental Security Income, Medicare Savings Program, and Social Security Benefits were excluded for the purpose of this analysis. Given that Medicare Part D does not cover this drug, we utilized the costs estimated by their cost plan finder as a proxy for any insurance plan that excludes PDE5-I given that this is the retail cost at the pharmacy.\u003c/p\u003e\n \u003cp\u003eWe compared the cost of PDE5-I under Medicare part D at 1) hospital retail pharmacies (identified using twelve different zip codes encompassing areas with comprehensive urologic oncology centers) and 2) the three largest commercial retail pharmacies in the United States (CVS, Walgreens, and Walmart) to popular discount platforms GoodRx (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.goodrx.com\u003c/span\u003e\u003c/span\u003e), MCCPDC (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://costplusdrugs.com\u003c/span\u003e\u003c/span\u003e) and Amazon Pharmacy (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pharmacy.amazon.com\u003c/span\u003e\u003c/span\u003e) (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). Thus, the four Medicare Part D subgroups consisted of 1) Hospital-based, 2) CVS, 3) Walgreens and 4) Walmart. The twelve ZIP codes included 55902 (Rochester, MN), 44195 (Cleveland, OH), 10065 (New York City, NY), 77030 (Houston, TX), 21287 (Baltimore, MD), 90095 (Los Angeles, CA), 60611 (Chicago, IL), 48109 (Ann Arbor, MI), 37232 (Nashville, TN), 85054 (Phoenix, AZ), 19104 (Philadelphia, PA), and 02115 (Boston, MA).\u003c/p\u003e\n \u003cp\u003eThe annual cost for each ED medication dosage was obtained. For Amazon Pharmacy, the maximum dosage for Tadalafil was 10mg, so two tablets per day were used to represent the 20mg dosage. We identified the GoodRx drug reduction cost for CVS, Walmart and Walgreens. Data for this project were collected during the week of April 15th, 2024.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eThe median for the twelve zip codes Medicare Part D (hospital-based, CVS, Walgreens and Walmart), GoodRx CVS, GoodRx Walgreens, GoodRx Walmart, MCCPDC, and Amazon Pharmacy were calculated. These values are displayed in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. For visualization purposes, the median for all four Medicare Part D subgroups was obtained. Additionally, the median for the three GoodRx retail pharmacies was calculated. Statistical analyses and visualizations were conducted using R (V4.1.1)\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAnnual Costs of Erectile Dysfunction Medications based on platform\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eMedicare Part D\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eDiscount Platforms\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDrug\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCVS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWalgreens\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWalmart\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGoodRx CVS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGoodRx Walgreens\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGoodRx Walmart\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMCCPDC\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAmazon\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSildenafil 20mg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1 024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1 054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1 078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1 098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSildenafil 100mg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1 446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e22 528\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e22 542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e22 528\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e182\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTadalafil 2.5mg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4 721\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4 759\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4 723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4 740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTadalafil 20mg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25 210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25 222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25 235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25 218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVardenafil 10/20mg\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19 015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19 027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19 039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19 023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFor Sildenafil 20mg, the Part D annual OOP costs including hospitals and retails pharmacies were comparable ranging from \u003cspan\u003e$\u003c/span\u003e1 024-\u003cspan\u003e$\u003c/span\u003e1 098 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The annual OOP cost of discount platforms was cheaper, ranging from \u003cspan\u003e$\u003c/span\u003e82-\u003cspan\u003e$\u003c/span\u003e275. For Sildenafil 100mg, the hospital-based pharmacies had a median annual OOP cost of \u003cspan\u003e$\u003c/span\u003e1 446, whereas retail pharmacies under Part D ranged from \u003cspan\u003e$\u003c/span\u003e22 528-\u003cspan\u003e$\u003c/span\u003e22 542. Discount platforms for this drug were preferred at an annual OOP cost of \u003cspan\u003e$\u003c/span\u003e89-\u003cspan\u003e$\u003c/span\u003e324. For Tadalafil 2.5mg, the annual OOP cost in Part D groups ranged from \u003cspan\u003e$\u003c/span\u003e4 721-\u003cspan\u003e$\u003c/span\u003e4 759 as compared to the range of \u003cspan\u003e$\u003c/span\u003e82-\u003cspan\u003e$\u003c/span\u003e312 for discount platforms. For Tadalafil 20mg, the annual OOP cost via Part D ranged from \u003cspan\u003e$\u003c/span\u003e25 210-\u003cspan\u003e$\u003c/span\u003e25 235, whereas the discount platform cost ranged from \u003cspan\u003e$\u003c/span\u003e103-\u003cspan\u003e$\u003c/span\u003e496. Vardenafil (both 10 and 20mg) ranged from \u003cspan\u003e$\u003c/span\u003e19 015-\u003cspan\u003e$\u003c/span\u003e19 039 from Part D groups and \u003cspan\u003e$\u003c/span\u003e86\u0026ndash;418 from discount platform. For both sildenafil dosages and tadalafil dosages, MCCPDC was the most affordable option. For both Vardenafil, GoodRx CVS was the cheapest option.\u003c/p\u003e \u003cp\u003eWe then combined the four-Part D subgroups as well as the three pharmacies analyzed with GoodRx discounts to directly compare these purchasing options. For the lowest prescribed dose of sildenafil (20mg) and tadalafil (2.5mg), the annual OOP cost to patients was \u003cspan\u003e$\u003c/span\u003e1 066 and \u003cspan\u003e$\u003c/span\u003e4 372. Under GoodRx, patients would incur an annual OOP fee of \u003cspan\u003e$\u003c/span\u003e251, and \u003cspan\u003e$\u003c/span\u003e282 resulting in an annual savings of \u003cspan\u003e$\u003c/span\u003e815 and \u003cspan\u003e$\u003c/span\u003e4 090 respectively. More drastic OOP costs were observed for sildenafil 100mg and tadalafil 20mg with Part D incurring a \u003cspan\u003e$\u003c/span\u003e22,528 and \u003cspan\u003e$\u003c/span\u003e25,220, respectively, compared to the \u003cspan\u003e$\u003c/span\u003e312 and \u003cspan\u003e$\u003c/span\u003e311 cost via GoodRx, patients would save \u003cspan\u003e$\u003c/span\u003e22 216 and \u003cspan\u003e$\u003c/span\u003e24 909 on these respective medications. We saw similar trends for the other discount pharmacies including Amazon and MCCPDC compared to Part D Medicare (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study compares the annual costs of the most common ED medication used by patients across four platforms: Medicare Part D, GoodRx at select retail pharmacies, Mark Cuban Cost Plus, and Amazon Pharmacy. Consistently, across different medications and dosages, we observed that discount platforms were significantly cheaper options compared to Medicare Part D. The results suggest that discount pharmacies provide prescription drugs at prices that offer significant cost-savings for patients when compared to conventional retail stores under Medicare Part D.\u003c/p\u003e \u003cp\u003eOur findings are consistent with prior studies. In a study by Schloegel et al., prices of twelve drugs commonly used to treat urologic conditions available on MCCPDC were compared to local retail pharmacies in Lexington, Kentucky. Their analysis suggested that MCCPDC offered savings for 9 of the 12 urological drugs available on the website which contribute to significant cost savings over the course of a patient\u0026rsquo;s lifetime (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). As in our study, MCCPDC has proven to be an effective tool for consistently low and transparent drug pricing for patients. In another study by Pockros et al., the variability of OOP costs for frequently prescribed medication for advanced prostate cancer on available Medicare Part D drug plans was analyzed. Depending on the specific plan chosen by the patient, potential cost savings were up to \u003cspan\u003e$\u003c/span\u003e2 512 for enzalutamide and \u003cspan\u003e$\u003c/span\u003e9 321 for abiraterone demonstrating the high variability of cost to patients in these drugs plans (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Although Medicare Part D plans provide coverage for certain drugs, it fails to provide any assistance for patients needing coverage for medications to treat ED. This complicates drug purchasing for patients and can lead to undue financial burden and non-compliance.\u003c/p\u003e \u003cp\u003eAn advantage of this study is the direct comparison of costs of drugs to the patient. We anticipate that these findings will provide prescribers with a clearer understanding of the cost burden and insurance limitations associated with PDE5-I within the Medicare population. Additionally, this study aims to highlight the frequent exclusion of these medications from coverage plans, helping clinicians make more informed treatment decisions for their patients. Physicians are not always reliable sources for information regarding healthcare costs, leaving patients without proper guidance (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). One study surveying 371 primary care physicians and specialists found that only 21% of physicians were able to estimate out-of-pocket costs accurately enough to discuss financial trade-offs with their patients (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Other studies have found that doctors consistently overestimate the cost of cheaper drugs but underestimate the cost of more expensive ones (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The high out of pocket costs for certain prescription medications may be a significant barrier for patients seeking treatment (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). To address these previously identified challenges, this study provides concrete cost-saving data, giving providers specific pricing information to facilitate more informed discussions with patients.\u003c/p\u003e \u003cp\u003eMedicare Part D Plan Finder, GoodRx, MCCPDC, and Amazon pharmacy have all been recognized as tools that provide patients with affordable prescription options. Per recommendations, patients should use the Medicare Part D Plan Finder annually to compare drug plans and visit GoodRx for urgent prescription refills. For recurring generic prescriptions, the MCCPDC is beneficial, while Amazon RxPass is ideal for those on three or more chronic medications (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is important to note that with the passage of the Inflation Reduction Act in 2022, Medicare Part D beneficiaries will see a significant benefit starting in 2025, with a \u003cspan\u003e$\u003c/span\u003e2,000 cap on out-of-pocket prescription drug costs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This change offers substantial financial relief, particularly for those managing multiple high-cost chronic medications. However, cost-saving platforms will continue to provide meaningful advantages for patients, especially those with fewer annual medication needs. Additionally, while our analysis uses national average pricing, it does not factor in the geographic variability in drug costs, which has been widely reported and may have a notable impact on specific patient populations (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The consistent nationwide pricing offered by MCCPDC and Amazon Pharmacy further underscores how these platforms can provide patients with transparent, cost-effective options.\u003c/p\u003e \u003cp\u003eOne of the key strengths of this study is the broad generalizability of the data. The pricing estimates from Medicare Part D serve as proxy pricing for insurance plans that do not cover PDE5-I such as Medicaid and certain commercial health insurance plans. This is because Medicare Part D finder estimates the cost of the drugs at these pharmacies without insurance coverage given the exclusion of these drugs. As a result, any individual without coverage for PDE5-I would encounter similar OOP costs, including those with commercial insurance plans who are ineligible for Medicare. As previously discussed, it is estimated that up to 75% of commercial insurance plans do not cover PDE5-I (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This makes our findings generalizable beyond the Medicare Part D population and can be used to estimate the impact to any individual without insurance coverage of these medications.\u003c/p\u003e \u003cp\u003eThis study offers valuable insights into the financial challenges faced by men with ED and prostate cancer survivors experiencing post-treatment ED. To our knowledge, this is the first study to compare these specific platforms directly as it relates to out-of-pocket cost without insurance coverage. This analysis highlights the considerable cost disparity between traditional retail drugstores under and discount platforms like GoodRx, MCCPDC, and Amazon Pharmacy which can provide significant savings. Insights from this analysis are helpful for healthcare providers to more informatively counsel patients to help ensure cost-effective access to ED medications.\u003c/p\u003e \u003cp\u003eThis study is not without limitations. Firstly, the cost comparisons are based on prescription prices at a single point in time, which may not account for fluctuations or changes in dynamic markets. Additionally, the analysis focused on a limited number of zip codes and retail pharmacies, which may not fully capture geographic variations in pricing and availability. The study also excluded certain financial assistance programs such as Medicaid, Supplemental Security Income, and Medicare Savings Programs, which could affect out-of-pocket costs for some patients. Furthermore, potential differences in medication quality and efficacy between online and retail pharmacy options were not considered. Future research should address these limitations by incorporating a broader range of data sources, patient demographics, and longitudinal cost analyses.\u003c/p\u003e \u003cp\u003eIn conclusion, patients being treated for ED with PDE5-I can encounter significant annual cost savings, on the magnitude of thousands of dollars per year, when utilizing discount platforms such as GoodRx, MCCPDC, or Amazon pharmacy when compared to costs under traditional coverage plans such as Medicare Part D. The lack of appropriate coverage of PDE5-I by traditional insurance plans can limit access to patients resulting in non-compliance or undue financial burden. The findings of these studies should be utilized when counseling patients. Healthcare providers should educate patients on these alternative platforms to increase access to essential medication and alleviate financial burdens for this common urologic condition.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData on annual out of pocket costs for erectile dysfunction medication was extracted from The Medicare Part D Plan Finder (www.medicare.gov/plan-compare). This tool was developed by the U.S. Centers for Medicare \u0026amp; Medicaid Services and is publicly available\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the U.S. Centers for Medicare \u0026amp; Medicaid Services for providing public access to Medicare Part D Plan Finder data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGurayah\u003c/strong\u003e: data curation, methodology, formal analysis, and writing - original draft, review, and editing; \u003cstrong\u003eKuchakulla\u003c/strong\u003e: data curation, writing - original draft, review, and editing; \u003cstrong\u003eThorogood\u003c/strong\u003e: writing - original draft, review, and editing; \u003cstrong\u003eFisch\u003c/strong\u003e: writing - original draft, review, and editing; \u0026nbsp;\u003cstrong\u003eDavuluri\u003c/strong\u003e: conceptualization, investigation, methodology, project administration, writing - review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was required to complete this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis data contains no PHI so ethics approval was not warranted to conduct this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no competing financial interests in relation to the work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePockros B, Cortese BD, Michel K, Ellis TA, Talwar R. Online Tools to Decrease Out-of-Pocket Prescription Costs for Patients: A Practical Guide for Urologists. Urol Pract. 2024;11(3):454\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151(1):54\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHudnall MT, Ambulkar SS, Lai JD, Pham MN, Fantus RJ, Keeter MK, Wren J, Bennett NE, Brannigan RE, Halpern JA. Characteristics of men who use direct-to-consumer men's health telemedicine services. Int J Impot Res. 2023;35(8):753\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurnett AL, Edwards NC, Barrett TM, Nitschelm KD, Bhattacharyya SK. Addressing Health-Care System Inequities in the Management of Erectile Dysfunction: A Call to Action. Am J Mens Health. 2020;14(5):1557988320965078.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurnett AL, Nehra A, Breau RH, Culkin DJ, Faraday MM, Hakim LS, Heidelbaugh J, Khera M, McVary KT, Miner MM, et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018;200(3):633\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung E, Brock G. Sexual rehabilitation and cancer survivorship: a state of art review of current literature and management strategies in male sexual dysfunction among prostate cancer survivors. J Sex Med. 2013;10 Suppl 1:102\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpencer SH, Suda KJ, Smith BM, Huo Z, Bailey L, Jr., Stroupe KT. Erectile Dysfunction Medication Use in Veterans Eligible for Medicare Part D. J Manag Care Spec Pharm. 2016;22(7):818\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurnett AL, Rojanasarot S, Amorosi SL. An Analysis of a Commercial Database on the Use of Erectile Dysfunction Treatments for Men With Employer-Sponsored Health Insurance. Urology. 2021;149:140\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePockros B, Shabet C, Stensland K, Herrel L. Out-of-Pocket Costs for Prostate Cancer Medications Substantially Vary by Medicare Part D Plan: An Online Tool Presents an Opportunity to Mitigate Financial Toxicity. Urol Pract. 2023;10(5):467\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. National Pharmacy Market Summary 2021 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.onekeydata.com/downloads/reports/2021_US_Pharmacy_Market_Report.pdf\u003c/span\u003e\u003cspan address=\"https://www.onekeydata.com/downloads/reports/2021_US_Pharmacy_Market_Report.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShih YT, Chien CR. A review of cost communication in oncology: Patient attitude, provider acceptance, and outcome assessment. Cancer. 2017;123(6):928\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSloan CE, Millo L, Gutterman S, Ubel PA. Accuracy of Physician Estimates of Out-of-Pocket Costs for Medication Filling. JAMA Netw Open. 2021;4(11):e2133188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007;4(9):e283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiggs KR, Ubel PA. Overcoming barriers to discussing out-of-pocket costs with patients. JAMA Intern Med. 2014;174(6):849\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKazi DS, DeJong C, Chen R, Wadhera RK, Tseng CW. The Inflation Reduction Act and Out-of-Pocket Drug Costs for Medicare Beneficiaries With Cardiovascular Disease. J Am Coll Cardiol. 2023;81(21):2103\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGellad WF, Choudhry NK, Friedberg MW, Brookhart MA, Haas JS, Shrank WH. Variation in drug prices at pharmacies: are prices higher in poorer areas? Health Serv Res. 2009;44(2 Pt 1):606\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Erectile Dysfunction, PDE-5 Inhibitors, Discount Pharmacy, Medicare","lastPublishedDoi":"10.21203/rs.3.rs-5257265/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5257265/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eOur objective was to understand the out-of-pocket (OOP) annual costs for PDE5-I to treat erectile dysfunction (ED) through traditional Medicare Part D drug coverage programs and other popular discount programs.\u003c/p\u003e\n\u003cp\u003eWe collected data on annual OOP costs for ED medications from four different sources: Medicare Part D, GoodRx, Mark Cuban Cost Plus Drug Company (MCCPDC), and Amazon Pharmacy. We compared the cost of lowest and highest routinely prescribed dosage of medications for Sildenafil, Tadalafil, and Vardenafil. We examined the cost of PDE5-I under Medicare Part D at 1) hospital retail pharmacies (using twelve zip codes encompassing areas with comprehensive urologic oncology centers) and 2) three most prevalent commercial retail pharmacies (CVS, Walgreens, and Walmart). These findings were compared to discount platforms GoodRx (via CVS, Walgreens, and Walmart), MCCPDC, and Amazon Pharmacy using R (V4.1.1).\u003c/p\u003e\n\u003cp\u003eFor Sildenafil 20mg, the Part D annual OOP costs including hospitals and retail pharmacies were comparable ranging from $1 024-$1 098. The cost at discount platforms was cheaper, ranging from $82-$275. For Sildenafil 100mg, the hospital-based pharmacies had a median price of $1 446, whereas retail pharmacies under Part D ranged from $22 528-$22 542. Discount platforms were preferred at $89-$324. For Tadalafil 2.5mg, the Part D groups ranged from $4 721-$4 759. The cost of this drug via discount platforms was much lower, ranging from $82-$312. For Tadalafil 20mg, the cost via Part D ranged from $25 210-$25 235. The discount platforms were reported to have lower costs ranging from $103-$496. Vardenafil ranged from $19 015-$19 039 from Part D groups and $86-418 from discount platforms. For both sildenafil dosages and tadalafil dosages, MCCPDC was the most affordable option.\u003c/p\u003e\n\u003cp\u003eThere are significant cost-savings when utilizing drug discount platforms. These options should be presented to patients to help improve accessibility and compliance to medications for ED.\u003c/p\u003e","manuscriptTitle":"The Price of ED: Annual Out of Pocket Cost Disparities of Erectile Dysfunction Medications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-24 05:28:42","doi":"10.21203/rs.3.rs-5257265/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0c74ee78-4c70-4523-94e6-df09999db10a","owner":[],"postedDate":"October 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":39143538,"name":"Health sciences/Health care/Quality of life"},{"id":39143539,"name":"Health sciences/Diseases/Reproductive disorders/Sexual dysfunction"}],"tags":[],"updatedAt":"2024-11-19T09:41:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-24 05:28:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5257265","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5257265","identity":"rs-5257265","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}