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As the direct-to-consumer pharmacy market grows -- notably with the launch of Mark Cuban's last year and earlier this year -- the question remains as to whether these ventures will have an impact on one of the biggest expenditures in U.S. healthcare: prescription drug costs.

Companies have largely targeted generic drugs, which make up some 90% of U.S. prescriptions -- but these only account for about 10% to 20% of drug spending, healthcare economists said.

And unfortunately, these companies stand less of a chance of bringing down the cost of higher-priced, branded drugs that account for the majority of drug spending, sources said.

Nonetheless, they may be chipping away at the market dominance of pharmacy benefit managers (PBMs), who have long been the gatekeepers of access to medications. PBMs are taking notice of the competition, especially as they increasingly come under fire from Congress, which is currently proposing a aimed at them.

"Companies have seen the distortions that are created by the intermediaries, the PBMs, and the pharmaceutical supply chain, and they're saying, 'We're going to offer a different model, where we're transparent about the fees and markups we're charging, and we're going to make it a more consumer-friendly experience,'" said Erin Trish, PhD, co-director of the USC Schaeffer Center for Health Policy & Economics, who at Congressional hearings on PBM business practices.

While these companies have a long way to go before they can truly revolutionize the U.S. drug distribution system and have a major impact on healthcare spending, experts said, they may pose a business threat to PBMs, who could start losing out on administration fees, mail-order refills, and other revenue streams.

Game-Changers?

Offering cheap generics to cash-paying patients isn't new. Walmart led in the space with its $4 prescription list, launched in 2006, according to Hussain Lalani, MD, MPH, of Brigham and Women's Hospital and Harvard Medical School in Boston, who has studied generic drug costs.

and have also had their own programs in which members can pay lower prices on generics with cash, Lalani said, and and have their own "prescription savings" clubs offering cheap generics for cash pay.

But newer digital pharmacies may make it even more convenient for customers to buy cheaper generics with cash.

Amazon entered the market with its in January, offering Prime members unlimited access to about 60 generic drugs for just an additional $5 per month on top of their existing Prime subscription.

Mark Cuban's also focuses on generics, claiming to have more than 800 available for sale, at just 15% above what they pay manufacturers, plus a $3-per-prescription dispensing fee and $5 for shipping.

In general, all of these models are most helpful to people who are uninsured or underinsured, said Lalani. For instance, people with high-deductible health plans may be on the hook for the entire cost of their medications until they've met their annual deductible, he said.

"Cheap generic drugs can cost a lot more than they should because of this insurance benefit design problem," Lalani said. "In that case, you can get much cheaper deals by going to any of these direct-to-consumer pharmacies."

Both Lalani and Trish have conducted studies showing that federal payers could indeed save substantial amounts of money if they were able to get the cash-pay pharmacy rates for generics.

In 2021, Trish and colleagues that Medicare overpaid for 43% of the most common generic medications in 2018, and could have saved $2.6 billion on these 184 drugs if they had been purchased at Costco's prices instead.

Lalani and colleagues conducted a similar study, , finding that Medicare could have saved nearly $4 billion by purchasing generic drugs at the prices offered by Cost Plus Drugs. They compared the price of 89 generics sold by Cost Plus Drugs in 2022 with the price paid by Medicare Part D plans in 2020. After adjusting for changes in drug costs during that time, they found Medicare paid more for 77 drugs, at a cost of $7.8 billion versus $4.5 billion.

"The presence of insurance benefits has led to overpriced amounts being charged to health plans for those generic drugs," Trish said. "Consumers are paying for that through higher insurance premiums and higher spending, because of the opacity in the market."

She noted that "rebates" earned by PBMs have particularly drawn the ire of consumers and regulators, as those savings are not often shared with patients at the pharmacy counter.

The Branded Problem

However, the bigger problems with affordability often come from brand-name prescription drugs -- which these companies don't really address in any significant way, Lalani said.

"Expensive brand-name cancer therapies are not available. Clinician-administered drugs that you get at a doctor's office or hospital are not available. Expensive drugs like semaglutide [Ozempic, Wegovy] are not available," he noted.

Cost Plus Drugs did announce its first branded offering, the SGLT2 inhibitor canagliflozin (Invokana) for diabetes, but it has a unique story, Lalani said.

Canagliflozin's competitors, empagliflozin (Jardiance) and dapagliflozin (Farxiga), have far more market share, he explained. Manufacturer Janssen may have sensed an opportunity to partner with Cost Plus Drugs to grow its market share in the SGLT2 landscape.

"There are going to be challenges to make brand-name prescription drugs affordable through this route," Lalani said.

Trish noted that manufacturers are also apprehensive about the consequences of angering PBMs, such as not being able to get on their formularies, as that's the typical route for making money off their products.

But if PBMs are in the crosshairs of policymakers over their rebates and other challenges with market opacity, she said, companies like Cost Plus Drugs may be poised to take advantage.

Manufacturers may also be less willing to play the rebate game in the coming years, Trish said. This has already been seen with insulin prices, as Eli Lilly, Novo Nordisk, and Sanofi recently dropped the list prices of their insulin "and said it's not worth it to play these games anymore," she said.

At the same time, the question remains as to the intention of these companies and what part of the healthcare market they envision fitting into, experts said.

Cost Plus Drugs may not remain solely a direct-to-consumer product, Trish said. The company has been exploring ways to engage with employers and health plans to offer access to their pricing, recently with the health plan Capital Blue Cross in Pennsylvania.

Amazon may also be angling to grow in the healthcare market, said Stephen Parente, PhD, MPH, chair of health finance at the University of Minnesota in Minneapolis. Its RxPass product could be viewed as a loss-leader -- something that is offered so cheaply the company may take a loss on it, but it draws in new customers and ultimately more money -- to increase Prime subscriptions or to bring it deeper into healthcare, he said.

Indeed, the company purchased the primary care provider One Medical last year.

"If Amazon does this well, and has the phone increasingly become the hub of how consumers think about healthcare," Parente said, "that could be very clever."

It's not guaranteed that those expansions would enable the companies to further bring down healthcare costs, particularly when it comes to prescription drugs.

Yet at the consumer level, Lalani said, these pharmacies and the cheaper alternatives they offer may be serving a legitimate need.

"For patients who are facing the choice of having to put food on the table or buying their medicine," he said, "they are financially incentivized to find a cheaper option."

Correction: This story was updated to reflect that Medicare paid $7.8 million in Lalani's Cost Plus Drugs study.

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