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My related medical essay 'My Multiple Myeloma Cancer log' is here

Four related erectile dysfunction drugs
Cost saving tricks
        1) Pill splitter
        2) Revatio an off-label Viagra equivalent
         Sildenafil backstory
        3) Offshore pharmacies
         PharmacyChecker.com -- offshore pharmacies vetted
Tools to get the real (discount) price (link)
        Updated drug discount tool list (3/18/16 update)
         1) Blink Health
         2) State drug discount cards
         3) LowestMed
         4) GoodRx
         Use GoodRx to check Medicare Part D coverage
        Bottom line on Revatio/sildenafil discount price
Drug price compare sites --- GoodRx, etc
        'State' drug discount cards available in nearly every state
        MA state discount card and price search
What's with all these stupid coupons! (link)
        Massachusetts Drug Card details
        I figure out who is behind the MA drug discount card
        Comparing MA pricing and GoodRx pricing
        Huge price variations even at chain pharmacies
        I try to get a price on the phone
Success --- I buy sildenafil (20 mg) locally for less than a buck a pill!
Summary --- Key steps to convert Viagra to (generic) Revatio
Updates
       FDA has approved generic Viagra
       Cancer drugs price search

Dealing with local pharmacies
      Buying prescription sleep pills at local CVS -- shorn like a sheep
      Obtaining a copy of your prescriptions
      Price shopping at local pharmacies (5/20/17)
          Cannot get a price quote in advance!
          Prepay should minimize pricing surprises

Appendix
Doctors selling generic Viagra
Sildenafil story
        Med Savers pharmacy
Prescription basics
        Getting a prescription to a pharmacy
        Prescription security
        Does my prescription cover generics?
Qualifying for part D coverage
Backstory on why no erectile dysfunction insurance coverage
Basic data on four erectile dysfunction drugs
        Response curves
        Viagra ? Revatio ingredients compared
        Indian manufacturers found from sildenafil pill images
 

        This started out to be an essay on buying erectile dysfunction, but I soon found the real story is the big savings offered by a new class of drug discount cards and plans, such as Blink Health, LowestMed, etc. These allow individuals to buy drugs at local pharmacies at heavily discounted prices, a price that institutions pay. These discount cards and plans make sense when regular health insurance does not cover a drug, such as erectile dysfunction drugs.

        The big gorilla with Viagra and the other erectile dysfunction drugs is that if you naively ask your doctor for a prescription and plan on filling it at your local  pharmacy, it will bankrupt you! The cost of these erectile drugs because of patent protection is outrageous, 40-50 dollars a pill, and they are rarely covered by insurance. Faced with this problem I did a lot of research and found there are some ways to save big bucks buying these drugs, so I've written up what I have learned in this little tutorial.

        Along the way I learned how to navigate in the murky world of prescription drug prices using specialized search sites and coupons. Information that is necessary to get a good price on Revatio (strategy #2), a low dose Viagra pill used off label.

Four related erectile dysfunction drugs
       There are four FDA approved erectile pills on the market, all quite similar: sildenafil (Viagra, sill-DEN-uh-fil), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra). They have the same mechanism of action and work from the users point of view pretty much the same, the big exception being Cialis, which is effective up to 4-5 times longer than the other three. These drugs are typically taken at either half or full dose with a recommended frequency of once per day.

        All of these drugs are patented and have only a single supplier when purchased at a US pharmacy. Also you can only purchase the drug for which your prescription is written. These reduce competition in this market, but this can't be the whole story. The big three (Viagra, Levitra, Cialis) have all been on the market for over a decade and to a large extent they are interchangeable, so why are prices so ridiculously high?  I think this stinks to the high heavens and smells of price fixing to me. Where is the FTC when you need them?  (Below I detail hard evidence that the cost of production is but a tiny fraction of the retail price.)

        However, despair not. Major reductions, even huge reductions, in the cost of erectile of erectile dysfunction drugs can be obtained if you understand the market, know a few tricks, have a cooperative doctor, and/or are willing to do a little work online. I'll begin with the simplest idea and then onto a special case and higher risk approaches that yield even greater cost savings.

        First I want to mention, and largely dismiss, a 'cost saving' approach that was suggested to me by my local CVS pharmacist. He said the major brands offered coupons online which could be used at the store to pay for a few pills allowing people to try their drugs for free.  Well, not really. For one thing you can only obtain the drug for which your prescription is written, so you can't easily sample the various brands to see which works best for you. In my case the prescription was written for Viagra and the Viagra coupon deal stinks: 50% off on the first few pills reducing the cost from $40/pill to $20/pill (six pills for $120), hardly free. I couldn't find any discount coupons for Levitra. Cialis offers 200 dollars off on your first order, so at $40 a pop that's five free pills, and Stendra offers three free pills.

Cost saving tricks
1) Pill splitter
        The simplest way to save money on all these drugs is to buy the maximum dose and cut the pill in half.  Curiously all the manufacturers sell the two largest dose pills at nearly the same price. You can take advantage of this if the smaller dose, often called the 'standard' dose, works for you, because the standard dose is half the max dose. My doctor handing me a sample jar of two 20 mg Levitra pills actually suggested I could cut them in half if I wanted to get a (standard) 10 mg dose. I did this using a knife and pliers and let me tell you this is not the way to do it, these pills are tough. To split pills you need a little gadget called a 'pill splitter' that holds the pill in place and bisects it with a little blade. Amazon sells a bunch of them. From the description and reviews my favorite is the 'Apex Ultra Pill Splitter' for $6.

2) Revatio an off-label Viagra equivalent
        Since the patents have not yet expired on any of the four major erectile dysfunction drugs, there are no generics for these drugs sold by US pharmacies. This will probably change in a few years as the patents on the oldest three drugs will be expiring. However, for the last couple of years there has been a little known way to buy legally what is essentially a generic Viagra pill sold under the name Revatio. You can read about Revatio on Wikipedia (sildenafil).

        Revatio is available both as a brand name (from Pfizer, same company that makes Viagra) and as generics. Revatio pills have exactly the same active ingredients as Viagra (see below) and most of the inactive ingredients are the same too, differing from Viagra only in color, shape, marking and dose. Revatio is available in only one dose (20 mg), so two to five Revatio pills must be swallowed to get a dose in the range of the standard (50 mg) or max dose (100 mg) of Viagra. To obtain Revatio from a US pharmacy your doctor must prescribe Revatio knowing it will be used 'off label'. How amenable doctors are to doing this I don't know, but medically the risks seem near zero because a Revatio pill is for all practical purposes just a lower dose Viagra pill.

Viagra to Revatio prescription change (12/18/15)
        Via my doctor's message system I requested a change in my (unfilled) Viagra prescription (quant 10, 50 mg) to cheaper Revatio (quant 90, 20 mg) to be used off label for erectile dysfunction and got a positive response. Since I didn't know whether my doctor was familiar with Revatio or not, I laid out the case that cost was the dominant concern with erectile dysfunction drugs and that Revatio is effectively a low dose Viagra pill with generics. I mentioned that I had used the sample Levitra he had given me at full and half dose without any side effects and moderate benefit. I included the GoodRx price for 90 pills from online and a local discount vendor showing that the price of an effective dose with Revatio is a tiny fraction of the cost of patent protected Viagra. My original Viagra prescription had been electronically transferred from my doctor's office to a local pharmacy, my new Revatio prescription is being mailed to me. I haven't received it yet, but can see from my drug list on my doctor's portal that it is for Revatio (quant 90, 20 mg) with three refills.

Printed prescription for Revatio in hand
        With my printed prescription in hand I see under my personal information it includes a line 'Pharmacy: CVS .....'. I hope this doesn't mean I can only use it at that pharmacy. (no problem) The prescription has a little text box that says: "Interchange is mandated unless the practitioner writes the words 'No Substitution' in the space above." I think this means that generics can (or must) be substituted for the brand name Revatio (from Pfizer). (Yup) The prescription is printed on paper with security devices, so I suspect only the original prescription will be accepted at local pharmacies. (Yup) I don't know yet what form of documentation an online US pharmacy will require.

        Next step in understanding how this system works, whether it might be covered by Medicare Part D, whether GoodRx discount coupons are any good, would be to take this prescription + coupons around to a few local pharmacies.

        A GoodRx search shows the cost of a 20 mg Revatio (sildenafil, quant 90) online is 0.65/pill, and at a discount US pharmacy like Kmart .84/pill, so even taking multiple pills getting your sildenafil fix from pills marked Revatio rather than Viagra will save you a factor of ten or more in cost (for a standard Viagra dose something like $2.50 vs $40)! However, it's important to shop around for this drug, because GoodRx reports 90 Revatio pills at local chain pharmacies, like CVS or Walgreens, can be much more expensive ($300 (3.33/pill) at CVS and $687 (7.63/pill at Walgreens)! The big cost differential here might be that the discount pharmacies are selling a generic and the local pharmacies are selling the brand name (Pfizer), but who knows. The non-profit Pulmonary Hypertension Association says Medicare Part D covers Revatio as a treatment for pulmonary hypertension.

        Pfizer on its Revatio site is offering a  $4/month copay card that claims potential savings as high as $500/month. They seems to be saying for $4 you can buy $500 worth of (brand name) Revatio and do this month after month. $4 is dirt cheap, but how much Revatio does this buy? Probably about 30 pills using pricing from GoodRx, and 30 Revatio is roughly equivalent to 6-10 Viagra. For $4 this is a very good deal, a 98% to 99% discount from the absurdly high price of Viagra. This offer seems too good to be true, and maybe it is. It comes with the restriction that you must get your doctor to prescribe brand name Revatio with no generic substitution. Pfizer also singles out MA residents for special attention: 'no card for you'.  And then I discover that this offer expires at the end of 2015 less than two weeks away (surprise!). (No change as of 12/31/15, still online and the card expires in 5 hours! A week later and Pfizer is still pushing the card deal although it has expired! What a company...) Yea, that sounds like a big drug company, a bait and switch deal, lock in the prescription to the high price brand name drug then cancel the discount offer!

        This crazy quilt pattern of a ten to one price variation I see for Revatio is just what Consumer Reports found for other prescription drugs. This Consumer Reports article on prescription drug price variations is well worth reading.

3) Offshore pharmacies
        Still bigger cost savings can be obtained by buying erectile dysfunction drugs from offshore pharmacies, often called Canadian pharmacies, but which may or may not be based in Canada, sometimes these are Indian pharmacies in disguise. The risk level rises here in that the product may not be as advertised or you may be dealing with scammers and no product will be delivered, or there could be a risk using your credit card. Consumer Reports recommends sticking with US pharmacies. I have not bought this way (to date) so have no personal experience to offer. I believe the process is that the drugs are mailed to you, and you pay postage and customs fees. Certainly the internet is filled with ads from offshore pharmacies for erectile dysfunction drugs, so there must be a big market. A further advantage is that unlike US pharmacies no prescription is needed.

Generic-4Less FAQ on why no prescription is needed
        "Why don't you need a prescription for you to sell your products off your website even though the products require one over the counter?
A doctors prescription is not necessary as we are an India based online pharmacy and function under different legal guidelines. FDA approved medicines can be lawfully imported into the USA along with a number of other countries around the world by individuals but ONLY for their personal use and not for re-sale."

        Besides selling erectile pills at an affordable price, non-prescription offshore pharmacies offer another advantage. You can easily try all the available drugs to see which you prefer. This is a big advantage. When you order one drug from them, some of them routinely throw in a few samples of another drug to try for free. When bought in the US via prescription from a local pharmacy, the only drug they will sell you is the drug specified by your doctor.

        Obviously the big issue is how to find a reliable offshore pharmacy. On the matter of quality it doesn't take a genius to figure out if an erectile drug is working or not! This is a problem I am now working. Here's my approach: read the sites carefully, check for user recommendations on forums, make a small test purchase, check to see the delivered product comes with a full detailed proscribing sheet. Some sites like www.generic-4less.com identify the Indian manufacturer, I like this transparency and take it as a good sign.

        For example Generic-4less.com quotes a price for 200 pills for the max dose of Viagra, Levitra or Cialis of 85-90 cents a pill, and $200 buys 400 Viagra (50 cent/pill). Compare this to the $40/pill that my local CVS quoted me, about x50 cheaper!  Of course these are the Indian made generics not the brand name drugs. (more on Indian generics below). Cut the pills in half and they will last twice as long.

PharmcyChecker.com -- offshore pharmacies vetted(5/12/17)
        In the 2017 book by medical reporter Elisabeth Rosenthal ('An American Sickness') she gives a useful reference for buying drugs offshore: PharmcyChecker.com. Started by a physician, it vets outside pharmacies. Since avoiding outright scams when buying overseas, some vetting could be very useful. I have not used this site (yet), but I may give it a trial

WHO WE ARE:
        PharmacyChecker.com (www.pharmacychecker.com) is the only independent company that verifies U.S. and international online pharmacies and compares prescription drug prices. Our verifications and price comparisons have been referenced by AARP Magazine, the New York Times, the Wall Street Journal, and many others. We were formed in 2002 when our founder, Tod Cooperman, M.D., saw that increasing numbers of Americans were looking on the Internet to save money on medication but did not have adequate information to protect their health.

        Tod Cooperman, M.D., Chief Executive Officer and Founder --- Dr. Tod Cooperman is a noted researcher, writer, and speaker on consumer healthcare issues. He has testified on health and nutrition issues before subcommittees of the Senate and House of Representatives and has been an invited lecturer at the National Institutes of Health. In addition to founding PharmacyChecker.com, Dr. Cooperman founded ConsumerLab.com (www.consumerlab.com), the leading independent evaluator of dietary supplements (vitamin, mineral, herbal, and non-herbal) and nutrition products. Dr. Cooperman also founded CareData Reports, Inc., an evaluator of consumer satisfaction with managed care (now a division of J.D. Power and Associates). Dr. Cooperman is a graduate of the Boston University School of Medicine and received his B.A. in medical science and economics from Boston University. He is a blogger for the Huffington Post's Healthy Living section.

        In the two months since I first wrote this essay there have been significant changes in the drug discount world necessitating a major update to this essay. The biggest change is the addition of Blink Health. This is pre-paid drug discount site with very good prices. It was not included in my original essay since it came to market only in Feb 2016 after the essay was written.  I have tried it and had good success with it. A second change is that state drug discount cards seem to have expanded their covered pharmacies, now showing CVS as a preferred pharmacy. For a while their unique local drug price search engine was gone from their sites, but it's back. Good as this is one of its best features. A further addition to the essay is LowestMed drug discount card which works a lot like the state drug discount card used to work. At some pharmacies they show very good prices.

Updated drug discount tool list (3/18/16)
        Here is my current list of drug discount tools in order of preference (best to worst). I have used #1 (Blink Health) and #2 (state drug discount cards) to buy 90 sildenafil (20 mg generic Viagra) and got a good price with both. I have not tried #3, but it looks interesting, potentially with the lowest price. I've included GoodRx in the list only because it has gotten a lot of press, but I don't recommend it because its prices are far too high.

                1) Blink Health                                  Good price (prepaid)
                2) State drug discount cards              Competitive price (15% or so higher than Blink Health, CVS preferred pharmacy) (Example: MA card)
                3) LowestMed                                   Worth a try (variable prices, quite a good price at Walgreens)
                                                                                              (whoops, a week later 3/25/16 LowestMed price is no longer cheapest. Their lowest
                                                                                              price is now same as state drug discount card.)
                4) GoodRx                                        (not recommended)

        With tool #1 (Blink Health) I paid 62.52 (67.52 base price) picking up the drugs at my local CVS. With tool #2 (MA state drug discount card) I paid 77.58 at Walgreens. I recently got a quote of 76.54 at CVS using the MA state drug discount card. All these prices are much lower than the wildly inflated prices (hundreds of dollars) most pharmacies will charge the ordinary customer, those who don't know how to play this crazy discount game, when buying 90 generic Revatio (20 mg, Viagra).

        All of these tools are drug discount plans to be used when insurance doesn't apply. They all provide you with a coupon you bring to the pharmacy. (See below for What's with all these stupid coupons!) #2,#3,#4 are similar in that you pay at the pharmacy. #1 is different in that you prepay to Blink Health online with zero copay at pickup.

1) Blink Health
(6/13/17 update)
        I used Blink Health again for sildenafil (Revatio generic). It worked slick, and I got a good price. Earlier I got faked out by the MA drug discount card giving me a price of 43 at my local CVS, a price which I though was too good to be true, and it was to good to be true as I found out upon visiting CVS that its price was nearly double. So I went back to Blink Health. The price quoted by Blink Health for ninety 20 mg pills was 62 with 5 off for first time users (not me).

        However, for reasons not clear to me I paid only 52. At checked out there a minus 10 dollar 'account balance' term, which I don't understand, but I'll take it. There was no hassle. They had my credit card (a backup card) on file, I clicked Ok to charge, and then printed out the coupon. That was it, no login, no email issues, just pay and print. The coupon was accepted by my local CVS. Slick.
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        This is currently my favorite drug discount tool. Not only does it appear to have pretty low prices, but also you probably need go no further than your local pharmacy to get the drugs. You prepay to Blink Health online, and then they provide you (online) with a drug discount card (really a page) that you print out (or bring electronically on your phone). To pickup with zero copay you go to any of their approved 60,000 pharmacies. Amazingly you don't need to tell Blink Health where you are going. And from the reaction of pharmacists it appears that they don't have visibility into the price that you have paid.

        The first time you use Blink Health a certain amount of faith is required as you must prepay. Blink Health says their drug coupon will be accepted with zero copay at 60,000 pharmacies national wide including CVS, Walgreens, Rite Aid, Walmart, Kroger and Target. Risk is reduced because Blink Health provides means to return your money: "You can cancel your purchases at any time".

        I was tipped off to Blink Health by a reader of this essay. He prepaid Blink Health 23 for 30 sildenafil, and when he went to his local CVS to pickup the pharmacist said that would be 273. Yikes, this is x12 times the 'real' price! Hold on to your eyeteeth. When he handed the pharmacist his phone with the electronic Blink Health card, the copay was zero just as Blink Health had promised.

        Blink Health worked as promised for me too. I paid 62.52 (67.52 base price, 5 off for first purchase) to Blink Health for 90 sildenafil, printed out the card (single page), took it my local CVS and got the drugs with zero copay. While picking up my prepaid drugs at CVS, I had them 'run' my MA drug discount card (tool #2) to see how much the same drugs would have cost if I had used it instead of Blink Health. The quote was 76.54, which is competitive but 9 dollars more than the Blink Health base price. I later sucessfully used Blink Health to buy 90 sildenafil (67) at my local Walgreens pharmacy.

Saved 1,379 on 90 sildenafil pills! (7/29/16)
        Wow, did I really save 1,379 on 90 sildenafil pills with Blink Health? Well not really, but Walgreens (below) is telling me I did, referencing their phony 'cash' price. Below is a scan I made from Walgreens customer receipt I found attached to my bottle of 90 sildenafil pills. My actual cost, prepaid to Blink Health for the 90 pills, was 67 (0.74/pill), and my copay at the pharmacy as shown was 0.  But Walgreens, apparently still oblivious to Blink Health, is telling me the customer that without my "insurance" (Blink Health is not insurance) my cost would have been their (phony) 1,379 (15.32/pill)!

Walgreen's customer receipt with Blink Health purchase of 90 (generic) Revatio pills

        There's a couple of (minor) drawbacks to Blink Health. You have to sign up and give an email address. They also force you to click a box that you will accept text messages. My workaround here is to use my junk email address, which is essentially all spam. (Everyone should have a junk email address.) Turns out the email address was not even used in the purchase. After entering my credit card info, a box popped up to click here to print out the card (page). A second drawback is avoid (at least for now) the Blink Health android app. This app demanded payment almost immediately before explaining anything about where the drugs could be picked up. The Blink Health main site was fine, giving a long list of the pharmacies that could be used for pickup, and other useful information like a caution that you need to have a prescription for the drug and quantity you are paying for. Blink Health uses MedImpact as their benefit manager.

2) State drug discount cards (MA card)
        My first success in Jan 2016 at getting a good price for 90 sildenafil, which I detailed in my original essay below, was using the MA drug discount card, which I later found out is a private card cleverly marketed as a drug discount card for each state. Google: '(your state) drug discount card' to find the web site for this card in your state. What I liked about it, besides giving a good price was that it had low risk. It told you where to go and what the price would be. You only paid the pharmacy if they came through with the price the card promised.

        In the last month there have been some changes in state card web sites. For a while a feature I really liked, their unique local drug price search engine that tells you the price their card should deliver at local pharmacies, was gone, but as of 3/18/16 it's back.  Below are two screen captures for my area using the MA drug discount card, one taken (3/18/16) and one taken a month earlier.  A month ago it showed my local Walgreens charging 77.58 and my local CVS 1,266 with their card. I went to Walgreens and 77.58 is exactly what I paid. However, the latest price at CVS has changed to a 'real' discount price of 74.50, a factor of x20 lower than the phoney 'retail' price of 1,266. I got a recent quote at CVS with this card that was within two bucks of this listed price.

        They now say their card is "accepted at over 68,000 pharmacies around the country including most major chains." The state drug discount sites now list all the pharmacies that Blink Health does and more which they label as 'participating', but they identify one or two as 'preferred'. I checked half a dozen states and in each case their preferred pharmacy was only, or included, CVS. Note however that in my area the 'preferred' CVS price is only three bucks less than Walgreens price.

        To get the local pharmacy prices for the state drug discount card click the button called: 'Medication pricing', on next screen enter 'sildenafil, select from the list 'oral tablet'. On the quantity screen enter  '90', on next screen enter zip code an (optionally) adjust mile range. Up will come the prices with this card at local pharmacies.

Overview
       The overview is that discount prices for 90 sildenafil using the various discount sites runs from about 57 to 77 dollars. As you can see the state drug discount card is at the high end of this range. Blink Health is about in the middle. And LowestMed claims they are at the low end (at some pharmacies), but this is not confirmed. I saved nine bucks switching from the state drug discount card to Blink Health, but LowestMed (below) is promising even more savings.

(update 5/15/2017)
     **  MA discount card reported the lowest price ever of 43 (quant 90, 20 mg sildenafil) at a local CVS, and a visit and call from CVS has confirmed this price.

3) LowestMed(3/18/16)
        The same reader that told me he had good success with Blink Health also mentioned that he was seeing good prices with the LowestMed drug discount card. I haven't tried the LowestMed card, so I have no personal experience to relate, however, I have checked out its web site. What I find interesting is that it seems to work the way the state drug discount cards did until recently. In other words it gives you (or appears to give you) the price at local pharmacies, you print out its discount card (no info need be entered), and pay at the pharmacy if the price is right.

        I used the LowestMed site to check out their prices for 90 sildenafil for my zip code. I have a good baseline to evaluate their prices because I recently purchased 90 sildenafil at both my local CVS (67 using Blink Health) and Walgreens (77 using state drug discount card). The price LowestMed shows for Walgreens is 58.36. This is the lowest I have seen, 9 less than I paid with Blink Health and 19 less than I paid with the state drug discount card. However, their CVS price is absurdly high at 286.

(Update 3/25/16)
        When I went to try LowestMed a week later to get more savings, I found their claimed 58.36 price was gone! Their lowest is now 77.58 (at Walgreens) exactly what I paid there with the state drug discount card. So at the present time this leaves Blink Health with the lowest price for 90 sildenafil: 67.52.

4) GoodRx
        While GoodRx drug price search site has some usefulness, getting a good price doesn't seem to be one of them! In the last couple of weeks I picked up sildenafil (90 pills) at my local CVS and Walgreens paying in the range of 67 to 77 dollars. When I recently checked the price for these pharmacies in my area in GoodRx, it gives me a price with their coupon of 286 (CVS) and 687 (Walgreens). Wow! Forget GoodRx for local pharmacies. GoodRx at this point seems to be largely dedicated to steering people to a single online vendor (HealthWarehouse) for which they quote a very good price 57.60. I assume they add shipping to this, but haven't bought here so don't really know.

        A lot of these drug discount sites have quirks, so it's best when shopping to try several. For example, one issue is quantity. What quantity is the drug you want made in? GoodRx was helpful here as it showed the maximum quantity for sildenafil was 90 pills. Why 90 pills? I no freaking idea, but this seems right as a check of the generic manufacturers of sildenafil show bottles of 90. With the quantity in hand you can ask your doctor to write the prescription for 90, and you know what to enter into other sites when they ask for the quantity.

Use GoodRx to check Medicare Part D coverage
        One nice feature of GoodRx is that it will tell you if the cost of a drug is covered by Medicare Part D.  This can be very useful to check if new, expensive drugs, like class 5 cancer drugs, are covered.  To check Medicare coverage click 'Medicare' under 'Prices' on left side of screen after first entering the name and dose of the drug.  As a test I used GoodRx to check Medicare coverage of cancer drugs Revlimid and Pomalyst, both of which cost over 10k/month.  In both cases it reported, "Yes, 100% of Medicare Part D and Medicare Advantage plans cover this drug."

Bottom line on Revatio/sildenafil discount price
        If you can get your doctor to give you a prescription for sildenafil (Revatio, generic low dose Viagra, suggested quant: 90) to be used off-label, any of the first three tools above should allow you to purchase 90 generic Revatio (20 mg) for between 57 to 77 dollars, very likely at a local pharmacy. Taking 2-3 pills (one gulp) provides a standard dose of real Viagra at about 5% of the absurd, patent protected price Pfizer extorts from its unsuspecting customers.
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Update on sildenafil/Revatio pricing (5/13/17)(5/17/17)
        Here's an update on sildenafil/Revatio discount prices about a year later [20 mg,  90 tablets].

      Lowest med                           74 CVS                                            (494 Walgreens)
      Blink Health                            62
      GoodRx                                 49 Target (CVS)         76 CVS?          (15 copay Walgreens with Medicare card )?
     MA state drug card                 43 CVS     (good price!)                     (494 Walgreens)                           (CVS price confirmed -- see below)
             (I'm pissed.  MA drug card recently reported a price of 43 at my local CVS. Knowing this was a good price I set off to buy it. I dropped in to have them request a prescription refill from my GP, and we had a long discussion on price with me saying what a good price this was (almost too good to be true). Next day I am called by the same pharmacist saying the prescription was in, but they didn't have the silldenafil in stock. Should they order it? I said yes. He said it would be ready for pick up the next day (today), and the price would be the price we discussed. At that point I updated this essay that the 43 CVS price was confirmed. But today when I went in to pick it up, I am told the CVS price with the MA drug discount card is not 43, but 83!  I was freaking lied to by CVS. No way I say and walked out. At home I recheck the MA drug discount price to see if might have changed, but no it still says 43

        My next steps are to try my local RiteAid (Reading) with the Ma drug discount card where it gives a price of 45. Also GoodRx is reporting a good price (49) with its coupon at Targets in my area that have embedded CVS pharmacies.
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        Two lower cost options have appeared 43 at CVS using the MA state drug discount card, and 49 at the CVS pharmacy in Target stores using Good Rx coupon. (GoodRx also shows sildenafil being bought with Medicare and a 15 copay, but I bet this is not for erectile dysfunction but is in someway restricted to reducing pulmonary hypertension.)
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Offshore search for sildenafil with Pharmacy Checker(5/13/17)
       Now using the new resource (PharmacyChecker.com) what about buying sildenafil/Revatio offshore? One of the advantages of off shore Viagra generics is that the available pill dose is not limited to 20 mg as it is the US. Entering the drug name brings up a long list of pharmacies and prices are all over the place, most of them very high. These sites are full of traps for unwary. They will happily sell you four pills for $60 if you don't know what you are doing. For example on the CandianRx site a search for 'sildenafil' brings up a list of dozens of options with various combinations of price, quantity and dose arranged randomly. A search for '88' finds the best deal: quant 88, 100 mg, for $34 ($32 for 88 50 mg)

        I don't see any cheap prices at 20 mg, but there are a few at 50 mg. The price/pill is a good first screen, but it doesn't include shipping, which can raise the price by 30%, so the second screen is the price listed (which includes shipping) for 88 pills.

        CanadianRx                              .36/pill                        32 (88 pills, 50 mg)                    34 for 88 pills, 100 mg
        CanadianDrugCenter                 .39/pill                         45 (88 pills, 50 mg)                   44 for 88 pills, 100 mg
        MedsEngage                             .41/pill                        47 (88 pills, 50 mg)                    41 for 88 pills, 100 mg
        DrugMartDirect                        .35/pill                        41 (88 pills, 50 mg)                     ----
        PharmStore.com                       .48/pill                        42 (88 pills, 50 mg)                     ----
        OffShoreCheapMeds                 .39/pill                        45 (88 pills, 50 mg)                      ----

        The pattern here for 50 mg pill is clear. The price is in the mid 40s for all the pharmacies except one CandianRx which is 32. In each case this is for 88, 50 mg pills. A 50 mg pill is the 'standard' Viagra dose,  x2.5 the dose of the 20 mg pill available in the US, so the price quoted here is about half the best US price. The biggest bargain looks to be the 100 mg pill pill. The 100 mg pills cost hardly any more than the 50 mg pills. This could be taken as the maximum dose or the pill cut in half to yield a half price standard dose.

         When I push into the sites Pharmacy Checker comes up with I often find the offerings are often very different from the PharmacyChecker listing. In some cases only the 20 mg pill seems to be available, however searching these sites is not easy. It takes a lot of scrolling around. A search for 88 is helpful.

Related search terms for sildenafil/Revatio:
        Some sites sell generic equivalents to Kamagra and Caverta, popular alternate brand names for sildenafil in 50/100 mg dose
.
                Kamagra -- Kamagra 100 mg is sold as a treatment for erectile dysfunction (ED). It’s manufactured in India and often sold online without a prescription.
                                             Many men buy Kamagra exported from India because they see it as a cheap alternative to Viagra, Cialis or Levitra. It is illegal to buy it in the UK.
                Caverta --- Another brand name for 50/100 mg sildenafil

             50 mg --- Suhagra, Caverta, Penegra
           100 mg --- Kamagra Gold, Suhagra, Manly,  Silagra, Penegra, Caverta, Kamagra Chew Tablets, Kamagra Effervescent

Open issues
        Do you want to give your credit card # to a pharmacy overseas? The first pharmacy I checked takes personal checks, but that means ordering via snail mail.
        Delivery of prescription

Documents to send to offshore pharmacies
        Found a 2015 story says credit cards may no long work at offshore pharmacies because Visa and Mastercharge have  joined an alliance to protect people from rogue and unsafe online pharmacies, which is defined as any pharmacy not in the US. However, I see it is not uncommon for for offshare pharmacies in 2017 to take credit cards. Of the three pharmacies I checked two appeared to take (only) credit cards and the third included personal checks.

        Since all the PharmacyChecker appoved pharmacies require a prescription for sildenafil, I just assumed (based on my exeriences with papeer prescriptions at local pharmacies) that a paper prescription on it security paper would need to be mailed to the offshore pharmacy. And indeed one of the offshore pharmacies I checked (CanadianDrugCenter) said exactly that. However, another (CanadianRx) said they accept for a prescription an email of a hires scan of the prescription. Or they have an 800 number that you ask your doctor to fax the prescription to. A third offshore pharmacy implied was not clear, but implied they too would accept a scanned copy of a prescription. The note that a customer can request a pharmacy to email to him a copy of his prescription, and I know that, because I have done it, that you can in person request a copy of your prescription at a local pharmacy and they will print it out for you.

Sildenafil dose on the prescription
        An open question on dose none of the site answered was this: Does the dose on the prescription have to match the order? I bet it does, but I see a potential problem. The only sildenafil (tablet) dose available in the US is 20 mg. So will a US doctor write a prescription for 50 or 100 mg, considering that it can only be fullfilled by an offshore pharmacy?

Bottom line on dealing with offshore pharmacies (re: sildenafil (Viagra generic))
        Used PharmacyChecker to screen for price saving and found no savings at all over domestic pharmacies using drug discount coupon for the standard 20 mg table. The price barely rises as dose is increased to 50 mg and 100 mg, so here there are substantial saving for a higher dose. However, to buy a 50 or 100 mg sildenafil tablet offshore probably requires (not verified) the prescription be written for the higher dose. This makes it offshore specific, not usable in US! Whether a US doctor would write such a prescription I don't know.

        Of the three top offshore pharmacies I checked the procedures to deal with them varied widely. One requires the original of a paper prescription to be mailed to them. Another said it would accept a copy (hires scan) of the prescription as an email attachment. One said it accepts personal checks, the other two didn't mention personal checks and appeared to only accept credit cards. All require you set up an account, and there were hints on one site that a fee might be involved. This is no walk in the park. A tel call would almost certainly be required to have them walk you through the procedure. In short it looks like a lot of work for a relatively small amount of savings, at least for the first order.
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Drug price compare sites --- GoodRx, etc
        The price comparison site GoodRx provides a useful service comparing prescription drug prices at different pharmacies. Consumer Reports mentions GoodRx in their article. The site is easy to use, just type in the drug name and up comes a list pharmacies sorted by price. Their price list typically includes local chain pharmacies (like CVS and Walgreens), discount pharmacies (like Walmart and Kroger), and a US based online pharmacy (HealthWarehouse). The low prices they quote generally require you use one of their coupons. I was initially put off by a forum poster cautioning that GoodRx was selling the personal information you enter to get the coupons, so he suggested using a using a junk email account and a google telephone number (whatever that is) to avoid being pestered with junk email and telemarketing calls from India. However, when I click GoodRx coupons for Revatio, there is no hassle, no information needs be provided. Just print the page with the coupon and bring it to the pharmacy. (more later on coupons)
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(update 2/17/16)
'State' drug discount cards available in nearly every state
        After writing this essay, I found out that the 'MA state drug discount card and price search' is not unique to Massachusetts. The (private) company behind it is 'United Networks of America'. In a clever marketing move they have rebranded their drug discount card ('UNA Rx Card') for every state and given it a state specific web site. I googled  'xx drug discount card' substituting for xx the initials for ten different states at random and each came up with a state drug discount card whose opening screens are nearly identical to the MA screen. For CA the card is called the 'California Rx card', for North Carolina 'North Carolina Drug Card', etc, but the layouts of the opening screens are all the same, each with its own drug price search button. If you scroll to the end, you find each card is really the 'UNA Rx Card' rebranded.

        So is this just another drug discount card?  No, it's better. These UNA Rx 'state' cards come with a price search tool that will tell you the price you will pay at a local pharmacy using the card. A huge advantage.

        Good, it means everything I write in this essay about the MA drug discount card and the MA drug price search is not unique to MA. It likely applies to all states, the exceptions being Montana and Vermont.
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MA state drug discount card and price search
       I later discovered another (and different) drug price comparison tool. This one provided by the state of MA to help MA patients navigate the drug pricing maze. It's accessed through the MA Drug Card site and has its own coupon (of sorts) called the 'MA Drug Card' -- "As a resident of Massachusetts, you and your family have access to a statewide Prescription Assistance Program (PAP). Create and print your FREE discount prescription drug card below." In my first experience with the MA price search engine, it was more accurate than GoodRx, and a real advantage is that it can provide prices for individual local pharmacies. Other states have drug discount cards and local price searches too, the Washington state site looks just like the MA site.

         http://www.madrugcard.com/medication-pricing.php                           (MA drug price search tool)

        Consumer Reports says pharmacies have contracts with insurance companies that specifies the amount they will receive for a drug , usually far lower than the list price (or cash price), which one consultant to the Consumer Reports article said is a fiction. From looking at the GoodRx coupons my first guess was that GoodRx might have deals with the pharmacies they list and are getting a commission for steering customers to those pharmacies. They say their coupons allow you access to insurance discount prices the pharmacy has with insurance companies, which is pretty much what the MA drug card site says too. How GoodRx makes money is a little obscure, maybe they get a commission from steering more customers to a pharmacy.

        How the GoodRx discount coupons work is also a little obscure. Below are three GoodRx coupons for Revatio that I got by clinking the discount link at three pharmacies: KMart, Target, and Walmart. On (12/21/15) the 'discount' price GoodRx reports for 90 Revatio varies from $58 (HealthWarehouse, online) to $801 (Rite-Aid). Yikes, a 14:1 variation! Notice how different the discount cards are. All the detail numbers on the right are different, some have the price, some don't, two say GoodRx but the Walmart card doesn't. To add to the confusion while the online coupons are tailored to particular pharmacies and drugs, GoodRx upon request will mail you a generic discount card that they say is good at virtually all pharmacies. On the GoodRx forum a lot of people report success with the discount cards, but others say they were rejected or it took days to get approval. When I google 'walmart pharmacy discount coupon', dozens of sites come up offering discount coupons for Walmart pharmacy and not one of the sites is Walmart.

        These GoodRx coupons look to be specific to a drug and a pharmacy, but that's misleading. I have in front of me the full print out of one of the GoodRx coupons below (Target) that includes text about the coupon. Here's what it says: "Will work at other pharmacies (prices may vary)" and "Can be used for all of your families prescriptions". In other words these are really (to some extent) generic discount coupons. There's other information too like can it, or can it not, be used with health insurance: "This coupon price may be lower than your health insurance co-pay, but it cannot be uses to lower your co-pay. Ask your pharmacist to help find the best price." In other words you either use a coupon or heath insurance. How does it work: "This coupon displays a contracted rate based on agreements between your pharmacy and a Pharmacy Benefit Manager."

Pharmacy Benefit Manager
        I kept reading about Pharmacy Benefit Managers, but didn't understand them. Turns out they have their own Wikipedia page (here). Briefly they are independent companies who offer to manage prescription drugs for companies that self insure for employees' health care. Originally they just did the paperwork (processing claims, buying the drugs and paying the pharmacies), but as major purchasers of drugs there were in a position to reduce drug costs for the companies hiring them. So now they negotiate discounts from the drug manufacturers, assemble formularies (list of covered drugs) and contract with pharmacies for the selling price of the formulary drugs. Pharmacy Benefit Managers are huge companies, the largest is Express Scripts which has revenue in excess of 100 billion.

.  . 

        I used GoodRx to check prices of the big three erectile dysfunction drugs and found little price variation. For these super high cost, patent protected brand name drugs there's no significant saving to be had by going to a discount pharmacy or an online pharmacy. The situation is very different with Revatio where there are generics that can be legally sold in the US. Here GoodRx (and other drug price search tools) prove their worth showing that US based discount and online pharmacy prices are as much as TEN times lower than prices at local chain pharmacies! There's other useful information on this site too like patent expiration dates and links to manufacturer's aid programs for expensive class 5 drugs. I learned, for example, that the patent on a 10k/month cancer drug I take will expire in 2019.

What's with all these stupid coupons!
        Shopping for prescription drugs is a zoo, ridiculously complex and convoluted. And what's with all these stupid coupons anyway! Politicians want patients to bear more of medical costs so customers shopping around can bring pressure to lower prices. The response in the drug world is to hide prices (just try and find a list of prices at a pharmacy for prescription drugs!), and it looks to me that coupons are just another gimmick thrown in to extract the super high list price from the occasional purchaser or unwary.

Drugs have several prices
        With a little more knowledge and thinking about it I now suspect coupons exist because they 'fit' with the crazy way prescription drugs are priced. There isn't one (customer) price for a prescription drug, there are several. A pharmacist confirmed this to me. These prices are set by contracts the (chain) pharmacies have with the various insurance companies and pharmacy benefit managers. (Even Medicare Part D (drugs) is administered by private insurance companies.) As best as I can figure, what various 'discount' coupons 'do' is allow the customer presenting it qualify for one of the available contract prices for that particular drug. This logic would say that all discount coupons are probably not alike, and while I suspect this is true, I can't document it.

Coupons as an obstacle to drug prices over the phone
        As I start trying to get drug prices over the phone, I'm beginning to suspect coupons have another purpose, to get customers in the door. The line you get over the phone is to get the 'discount' price, i.e. the real price, you need to bring in your prescription and discount card so they can 'run' the card. If pharmacies can get their hands on your prescription, they know they are likely to get the sale.

        Coupons make shopping for prescription drugs not covered by insurance unique. The system is so structured (rigged) that coupons are necessary if one is to get a price that is not hugely inflated. In other words to get the 'real' price. I know of no other product like this.

Massachusetts Drug Card details
        I learned from a visit to my local CVS pharmacy that even Massachusetts  has a drug discount card when it turned out their computers showed I had one (who knew!). Here's what it says about the MA drug discount card on the MA drug card web site.

* Free For Everyone. All residents are eligible to get pharmacy discounts through this program. The program can be used to supplement most health insurance plans including Health Savings Accounts (HSA) and High Deductible Plans. It can also be used as a Medicare Part D supplement by providing discounts on non-covered drugs. (This is confusingly worded. I think it means the card can be used if the insurance doesn't cover it, but it can't be used to lower an insurance copay.)

* No Restrictions. There are no enrollment forms, no age or income requirements, no waiting periods, no eligibility required, no exclusions, covers pre-existing conditions, no claim forms to file, no annual or lifetime limits. (Just click and print the (paper) card. That's what I did, and it was accepted at my local chain pharmacy)

* Lowest Price. This program has Lowest Rx Price Logic to guarantee that you get the best pricing on prescriptions. Card holders pay the lower of a discount off Average Wholesale Price-AWP, discount off MAC Pricing, or Pharmacy Promotional/Retail price. You can save up to 75% on your medications (average savings are roughly 30%)! (MA seems to be saying here their card guarantees the lowest price, and if true that makes this the best card for MA residents.) (update --- So much for this 'guarantee', my Blink Health purchase was ten bucks cheaper.)

* Medications. The program includes discounts on brand and generic medications, open formulary so that all medications are eligible for discounts.

* Accepted Everywhere. The Discount Prescription Card is pre-activated and accepted at over 68,000 pharmacies around the country including most major chains.

* Confidential. No personal information is required to get a card.

(source -- http://www.madrugcard.com/create.php)

I figure out who is behind the MA drug discount card
        I found out who is behind the the MA drug discount card. At the end of a Q?A on its site in teeny tiny print I find this:

Program Admin: UNA Rx Card,  Website Admin: United Networks of America
This is not a medicare prescription drug plan. Program is privately supported.
This is not a government run/affiliated/funded program.
Discounts are only available at participating pharmacies.
This program/card is a drug coupon. THIS IS NOT INSURANCE. More Info

        "The program administrator may obtain fees or rebates from manufacturers and/or pharmacies based on your prescription drug purchases. These fees or rebates may be retained by the program administrator."

(1/10/16 update)
        To use the MA search site effectively you need to know exactly what you are looking for, specifically the generic name and quantity. Unlike GoodRx this site does not by default include generics. For example, the price it reports when I enter brand name 'Revatio' is 35/pill ('cash price'), but when I enter generic name 'sildenafil', the price it reports is 0.87/pill. This is an astounding 40:1 price difference at the same pharmacy. Yikes! (I ended up buying generic Revatio for 0.87/pill at this pharmacy, so the MA generic price was spot on.)

         http://www.madrugcard.com/medication-pricing.php

Comparing MA pricing and GoodRx pricing
        I ran a comparison of the MA drug price search tool and GoodRx and discovered a little gremlin. I searched 90 Revatio (20 mg) on both sites. What a difference. The MA site price range is 2,746 to 2,910, including Target and Walmart. These prices are mind boggling high, 31/pill for what is essentially 1/5th of a 100 mg Viagra that sells for about 40. What a rip off!  Just goes to show if you don't do your homework pharmacies will pull out your eye teeth. A Revatio search on GoodRx is 57 to 801 (with GoodRx coupon). MA has Walmart price at 2,893 and GoodRx has Walmart at 114. What!! GoodRx is giving a Walmart price that is only 3.9% of the price the MA search tool!

        I have my suspicions as to what is going on. On the MA site I search again but this time using Revatio's generic name (sildenafil, 20 mg) and sure enough the price drops drastically (at least at some pharmacies) with the price range now 78 to 1,267. So apparently the MA site searches for the brand name only (ignoring that prescriptions say 'interchange mandated') whereas the GoodRx site search includes the generic when the brand name is entered. The MA site shows generic Revatio prices at several chain pharmacies near me (Walgreens, Stop and Shop, Rite Air, Osco) are quite low comparable to the discount pharmacies (Walmart).  (Target is also listed, but I suspect this is wrong as they have been taken over by CVS.) I am doubtful, this is a very different pattern from what GoodRx shows.

        However, there remain huge price differences at specific pharmacies at the two sites. Whereas MA says my local Walgreens and Rite Air are 78, GoodRx has them at 687 and 801 (with coupons) and about 1,600 ('cash price', i.e. without coupon). Somebody is very wrong. MA give the price for 90 pills of the generic Revatio (20 mg) at the two local chain pharmacies in town as 78 (Walgreens) and 1,267 (CVS). Yikes! The CVS price is x16 higher than the Walgreens price, or so says the MA search tool. The next step is to do some local pricing in person or by phone.

Huge price variations even at chain pharmacies (2/15/16) (3/18/16)
        Here (left) is the result of the MA drug card search engine for 90 sildenafil at pharmacies within a few miles of me. Only chain pharmacies come up and the result is quite amazing. According to this search engine all my local CVS chain pharmacies are charging x16 times more than all my local Walgreens! If true, CVS must be making a sweet profit on this one.

        But a month later (right) there's a huge change. Apparently CVS is now covered by the MA drug card since the price has come crashing down from 1,266 to 74.50. A recent quote using the card at CVS,  but without these prices in hand to show the pharmacist, was 76.54, two bucks higher than shown.

        This experience hints strongly as to how pharmacies use these discount cards and coupons. They are used to make it difficult to do price shopping for prescription drugs. Can't do it over the phone, you got to bring in your card (and prescription) so we can 'run' it. Seems logical, and I suspect this is rarely questioned, but it smells to me that it is either a ruse (or a very convenient feature of the software they use). The MA site tells MA residents that the MA drug card insures, basically they are saying guarantees, the lowest price as long as the card is accepted. If that is true, then there should be no need to 'run' a card, just quote the lowest insurance cost for the drug.

        What happened is that I walked out of Walgreens paying 77.58 for 90 generic Revatio (20 mg) pills exactly the MA price quote, but only after some sparing. Let me tell you how it went down.

How it went down
       I went in with my printed Revatio prescription, my MA drug discount card (in my wallet) and a Revatio discount coupon I found online. I also went in with a printout of the MA search tool results showing the 'estimated' price at this particular pharmacy was 77.58.  I handed the pharmacist the printed prescription and said I was doing a price search without insurance and mentioned I had some coupons, but didn't show them yet. She immediately went to the computer with my prescription in hand and after some typing told me the cost would be about 287 with a Walgreens card (which I don't have). I then pulled out my MA drug discount card and the printout of MA search price for this particular store showing 77.58, saying the MA card site says its card (if accepted) guarantees the lowest price. The pharmacist looked at the MA price printout a long time. Then after 5 min of typing told me the price would be 77.58, exactly the price on the MA price list. This new price (surprise!) was drastically lower than the 287 I had just been quoted minutes before (with Walgreens card) by the same person.  GoodRx price search was way off here saying the lowest Walgreens' price was 687 (using the GoodRx discount card, 1,608 cash price).

        I am finding this is a lot like buying a car. You got to go in prepared knowing what price is reasonable and make it pretty clear you won't buy if you don't get a  good price. After agreeing to buy, I mentioned I had this second Revatio coupon and asked if coupons were pretty much the same?  I didn't get a clear cut answer but came away with the impression that different coupons might result in different prices. I said to the pharmacist that it seemed like there were several prices for the same drug, and she confirmed this was the case.

        I'll note something the pharmacist did not say. She never mentioned insurance. True, I had asked to price this drug without insurance. I didn't mention I was going to use it off label (for erectile dysfunction) and she didn't ask. I thought it curious she didn't mention that Revatio (when used on label) is normally covered by insurance, including Medicare Part D. It would have been interesting to see what this copay would have been.

        I had to wait 40 minutes for the prescription, but this was OK as I walked to the nearby supermarket and did my shopping. She wouldn't return my printed prescription, saying she had to keep it. Here we see another gimmick by the pharmacies. They have your prescription, thus you are more likely to refill through them. Same price I wonder or will it magically shoot up when I go to refill?  If I want to refill at a different pharmacy, I would need to get the new pharmacy to 'pull' the prescription from my local Walgreens, and the Walgreens pharmacist mentioned this when I asked. She didn't mention refills, but I see that three refills are printed on the label. Nor did she say whether I was getting the brand name or the generic, so I asked, it's the generic. Later I saw the label on the pill bottle says: "sildenafil 20 mg tablets, mfg Camber - Interchange for Revatio 20 mg tablets", so that's how generics are indicated. As I had hoped the pill are tiny, so taking two or three in one gulp (40 to 60 mg dose) is not a problem.

         Googling the phrase on the label 'Camber - Interchange for Revatio 20 mg tablets' brings up the press release below. It shows the parent company of Camber Pharmaceuticals in NJ is Hetero Drugs of Hyderabad India, so there's a chance the generic sildenafil (low dose Viagra) pills I got from my local USA pharmacy were made in India. Walgreens dispensed my 90 pills not in the Camber bottle, but in a generic pill bottle.

        The paperwork that came with my CVS generic Revatio order had in teeny tiny print the words 'Torrent Pharma'. This is the name of the generic manufacturer of the Revatio (20 mg) they dispensed though they certainly don't make this clear. Curiously, as you can see below, Torrent Pharma also makes higher dose sildenafil tables, which I presume are only for sale outside the USA.

Sildenafil refill (2/15/16)
        Since first getting my first 90 sildenafil for $78, I was curious to see if when I went to refill the prescription if the price would (magically) go up. Well it didn't. Here's how it went down.

        I went back to the same Walgreens' pharmacy where I originally bought. I had my empty pill bottle and in my pocket my MA drug discount card and a printout of from the MA drug search for this pharmacy saying the price should be $78, which is what I originally paid. I presented only the pill bottle. The pharmacist proceeded to begin process the order without telling me the price. (God, I love how pharmacies operate!) So I asked the price saying I would only buy if the price was right. He said my "copay" would be $78. I said Ok, but it was not a copay, it was the price, no insurance was involved. Later I pulled out my MA drug discount card, and the pharmacist said that was what he was using. (It may be from the pharmacy's point of view a discount card is getting you a discounted insurance price, so they think of it as a copay. However, technically this is wrong as it says on the MA drug card site, "This program/card is a drug coupon. THIS IS NOT INSURANCE.")

        They had only 15 pills in stock (charging me $20), but I was assured that the total for the 90 pills would be $78. Above is a scan of the paper work for the 15 pills I got today from Walgreens. Notice what they show as the "Retail Price" of these 15 generic 20 mg pills: $275.95. Words fail me at outrageousness of this claim. It is equivalent to charging $92/pill for a 100 mg Viagra pill! And this is for a generic!

Summary --- Key steps to convert Viagra to (generic) Revatio
        1) Contact your doctor and ask prescription be changed from Viagra to Revatio (quant 90)
        2) Use specialized search tools (GoodRx, MA search, LowestMed, Blink Health) to search for good prices at local or online pharmacies
        3) Get a good discount card (for MA residents this might be the state MA drug card, or Blink Health, or possibly LowestMed)
        4) Tell pharmacist you are price shopping, show discount card and printout of the search engine price for that pharmacy
        5) If you have prepaid with Blink Health, your Blink Health card should result in zero copay at the pharmacy

Generic Viagra wins FDA approval
        Recent press announcement:

        "March 9, 2016 -- Today, the U.S. Food and Drug Administration approved the first generic version of Viagra (sildenafil citrate), for the treatment of erectile dysfunction. Teva Pharmaceutical Industries received approval to market generic sildenafil citrate tablets in 25 mg, 50 mg, and 100 mg strengths and has 180-day exclusivity."

FDA approval is misleading
        However, a look at the business press puts a different spin on this FDA announcement. Teva lost a patent fight with Pfizer about generic Viagra in 2011. Teva and Pfizer later struck a deal where Teva will be allowed to sell generic Viagra, but not before Dec 2017, and Teva will have to pay royalties to Pfizer. In other words this is not the classic generic drug competition where multiple companies rush in and prices crash. Generic Viagra from Teva is not going to come soon, and when it does is unlikely to be cheap.

Cancer drug  price search
        I take a super expensive class 5 cancer drug, a class of drugs where cost run to 100k/yr. I didn't expect that the drug search engines in this essay would be of any use here since these drugs are nearly all patent protected, single supplier drugs and would typically covered by insurance, but for fun I entered a new drug I am a candidate for (Ninlaro) into the engines, and the MA drug discount card search came through.

        Ninlaro is new to the market (Nov 2015) and is a super expensive pill (3k/pill, 9k/month). I have a baseline price for this drug because when it was approved by the FDA in Nov 2015, "A Takeda (drug manufacturer) spokesperson has informed The Beacon (multiple myeloma forum) that the wholesale price of a Ninlaro will be 8,670 per four-week cycle, or 2,890 per Ninlaro capsule". The MA drug search engine six months later (April 2016) reports prices of this drug in my local area range from [8,694 (Stop and Shop Pharmacy), 9,164 (Walgreens), 9,214 (CVS), three pills for a four week cycle] or in round numbers 8,700 to 9,200. This is interesting. One local pharmacy is selling the drug just 24 above its wholesale price, whereas three chain pharmacies have marked it up about 500 for a nice fat profit.

        Sure, no big percent savings here on a patent protected drug, but still 500 dollars is 500 dollars. With Medicare part D drug insurance coverage in 'catastrophic' mode, which applies for most of the year with these super expensive drugs, the patient pays 5% of the retail cost, so buying at the right pharmacy can reduce out of pocket monthly expenses about 25 (435 vs 460), the remaining 475 in savings accruing to the taxpayer.
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Dealing with local pharmacies

Buying prescription sleep pills at local CVS -- shorn like a sheep (2/8/17)
        Thinking the price would be low (plus I have Part D drug coverage) without doing any homework, but with prescription in hand, I walked to my local CVS to pick up some sleeping pills. Steroids are part of my chemo for cancer and steroids are well known to make sleep difficult. I have been living with a messed up sleep pattern on the days I take steroids this for a long time, so my oncologist recommended Ambien might be worth a try and wrote me out a prescription. Ambien is a drug I knew nothing about.

        I now know that brand name Ambien is very expense, 500 for 30 pills (17/pill), but Ambien has generics and regardless of what the prescription says (I didn't check the prescription) in MA a pharmacist is mandated by state law to deliver the generic not the brand name ('Interchange is mandated') unless the prescription forbids this.

        Things did not go smoothly at the pharmacy. I handed over my prescription and was told that my insurer (part D, drugs) required pre-approval, meaning the insurance company needed to contact the doctor before they would pay. As it was about 5:00 pm that meant I would not be able to pickup my pills that day. So I asked what would be the price "without insurance" and was told 35.64. I said OK, I would buy it without the insurance, later thinklng maybe I could get the part D approval post-purchase and be reinbursed. (When I asked later about whether post-purchase approval was possible, the clerk said she didn't know.)

        When I went to pay for my prescription (without insurance) I pulled out the MA drug discount card and asked what it would cost if this drug discount card was used. I was surprised to hear the clerk say the pricing I was getting was with that card (correct) as they had if for me in their system. This was no mention of use of any drug discount card when at drop off I was quoted a cost. I was a little pissed at having been misled, but the drugs were ready and it was only 35 so I paid it.

        Later at home I did what I should have done beforehand instead of naively wandering into a pharmacy to be shorn like a sheep. Here's what the discount card seaches tell me:

                    Brand name                             Ambien (30 pills, 5 mg)
                    generic name                           zolpidem tartrate (30 pills, 5 mg)
                    paid                                         35.64  (CVS used MA drug discount card which I had used there previously and was in their system)

MA drug card results (30 pills, 5 mg)
                   Abmien                                    515.84 (my local CVS) , Stop and Shop 486.49                                       (Yikes!)
                   zolpidem tartrate                      35.64  (my local CVS), Walgreens 25.41, Stop and Shop 11.98              (35.64 is what I paid)

Blink Health (30 pills, 5 mg)
                   zolpidem tartrate                      6.12

Shorn like a sheep
        So there it is, not doing my homework, justified I thought by my having Part D coverage, which the pre-approval requirement tripped me up. I ended up paying using the MA drug discount card, about 35 dollars at my local CVS, whereas I could have got it for 1/3rd of that at a local Stop and Shop. If I had prepaid with Blink Health, I could have got it at the same local CVS for 1/6th of what they charged me!  More proof your local pharmacy will abuse you if they can.

Obtaining a copy of your prescriptions (5/20/17)
       Elisabeth Rosenthal in her 2017 book 'An American Sickness" says your local pharmacy will be glad to email you a copy of your prescriptions. I thought this could be useful. I should have a file of my prescriptions. I take a lot of drugs, and the hospital routinely just forwards my prescriptions to my local pharmacy without giving me a copy. So following up on Rosenthal's suggestion I asked at my local CVS if they would email me a copy of my prescriptions in their system. Ans: no. Not only would they not do it, they claimed to be unable to do it, because there had no outside email service, their emails were only for internal use. So much for that avenue to obtaining prescriptions.

Price shopping at local pharmacies (may 20, 2017)
        Over the last couple of years I have relied on the various drug discount cards and plans to compare prices at pharmacies and have found that works pretty well. In the few times that I have actually bought this way price that the discount web site gives me at a particular pharmacy has turned out to be the price I paid.

        That fell apart recently when the MA drug discount card gave me a price of 43 for 90 sildenafil (Revatio generic) at my local CVS and on that basis I ordered the drug, and a phone call the next day from CVS seems to confirm that price which I had discussed in detail with the pharmacist the day before, but when I went to pick it up I was told the price with MA drug discount card was 83. I was pissed, saying I was lied to. There was no way I was going to pay that price when I remembered the going price range with discount cards and plans is 57 to 77, so I walked out.

Cannot get a price quote in advance!
        This episode reveals one of the tricks that pharmacies use making it difficult to price shop. When placing the order I discuss with the pharmacist the the drug discount card to be used (my MA drug discount card is on file at my local CVS and is routinely used). I go in knowing what the discount card price is and I ask the pharmacy when placing the order if they can confirm the price I will be paying using the card. And I am told NO we can't give you a price, we can only give you the price when you in to pick up the drug (or 'run the card') and pay! Really?

        Maybe there is an underlying reason why this might be so, but it smells of a technique adopted by the pharmacies to make it difficult to price shop. Think about it, with what other product is it not possible to obtain the price when you order the product? When the pharmacy calls and says your drug is ready to be picked up, they have already packaged and customized the you drugs for you, and it is at this point when you enter the pharmacy to pick up the drug that you learn the price.

        I have found with CVS that even when they call me they will not give me the price, hell they won't even tell me the name of the drug! I got some sort of 'explanation' from them that I take with a big grain of salt that due to some privacy concern it is not legal for them to identify the drug, even though it is them that are calling me. Sound ridiculously fishy  to me. And this is just another annoyance in dealing with my local pharmacy as I buy a lot of drugs from them and when they think a refill is due they will call me and it's not uncommon for me to not know what drug they are calling me about, so I either ignore the call or have to make a trip in to see what drug they want to sell me and at what price.

What's the next step?
        So what's my next step with the good price (43) the MA drug discount card is continuing to give me. CVS's says when they price using the MA drug discount card it comes up 83, yet the MA card site is telling me 43. I have no idea if the the MA drug card is telling me one price and a different rice to the pharmacy, or if it the CVS pharmacy is just not accepting the MA drug card price. There might be a Ma drug card customer service tel #/

        Do I go to another pharmacy?  There is a good option here, as the Rite Aid Pharmacy price (45) is almost as good as the CVS price, and there are a couple of Rite Aid pharmacies in a neighboring town, but it will be kind of a hassle requiring two trips. The prescription must be pulled from CVS and my Ma drug card # put into their system.

Checking the price at Rite Aid (5/20/17)
        A day later I made a second attempt to use the MA drug discount card to buy sildenafil, this time at a Rite Aid pharmacy.  This time I went in with all the drug price info from the MA drug site info printed out.  I started out by laying it out on the table and told the pharmacist that I was shopping on price. The MA drug card print out indicated that at this particular pharmacy 90 sildenafil pills with their card should cost 45. The pharmacist first said well 45 is what it will cost. (She didn't say she was familiar with the MA drug discount card, but acted as though she was.) I said I wouldn't buy if that was not the cost. I was going to take the pharmacy some work not only to prepare the order, but to first 'pull' my prescription from CVS.  It would save the pharmacy a lot of work if the price was not 45, And sure enough she said maybe I can run a dummy script, and a minute later said the price will be 78, so killed the transaction.

        I did get a price on ordering, but it was in the pharmacy's interest to do so, I had made it clear I was only going to buy if the price was right.

MA drug discont card price is WRONG (5/20/17)
        More importantly is this two failures of the MA drug discount card. I have used the card before for several different drugs, and it had been reliable. The Rite Aid pharmacist apparently thought so too, because she first said that the price would be what I had printed from the MA drug discount site (45), but when she checked that turned out not to be the case.

        Not good the MA drug discount card is not to be trusted. I knew the price was too good to be true. This discount site is telling me one price and then telling pharmacies a price about double this!

Prepay should minimize pricing surprises
        Note this pricing problem should not exist with Blink health where you prepay, and Blink Health assures you that there will be no copay at pickup. Too bad that its price is not the best.
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                                                                                                  Appendix

Doctors selling generic Viagra
        Doctors get into the act. Here's a story from a reader who related his personal experience:

        I was at my urologist office and my doctor asked me, "Do you want to buy some generic V___a?  We sell it here at the office - 45 pills for $100 cash price.” He declined and was later puzzled because he didn't think there was any generic Viagra. Well he began googling and found my essay and learned that Revatio is a low dose Viagra pill that can be bought cheaply since its patents expired and there are generics. He continued, "Then I figured it out.  My urologist was prescribing off-label usage and making a tidy profit dispensing pills from his office at a cost of more than double the going rate." Yup, the doctor was buying bottles of 90 generic Revatio for 57 to 77, then selling half the bottle for 100. Oh yea, doctors.

        I later heard a different radio commercial from Med Savers on Rush. It's not inaccurate, but it is a little misleading. The (short) radio commercial says 'sildenafil, the active ingredient of Viagra for less than 2 bucks a pill, save $30'. There is no mention that the sildenafil pill they are selling is a lower dose than Viagra, but five of their $2, 20 mg pills for $10 is equivalent to a maxium dose of Viagra (100 mg), so with a baseline price of $40/Viagra pill their claim of a $30 saving is correct.

        I called their toll free number to inquire about whether I could use my prescription for 90 sildenafil pills. Ans: yes. I was given a price over the phone of  $109.70 for 90 pills ( $1.22/pill) with free shipping. I asked about documentation for the prescription. They require a prescription, either it needs to be mailed to them, transferred from an existing pharmacy, or contact your doctor to forward the prescription to them.

        Three things are notable here. One, this is a pharmacy itself, not an outside group with insurance contracts, selling at a steep discount. Two, while at $110 for 90 pills they are making a good profit, this is the first sildenafil source I am aware of where customers can avoid all this coupon nonsense. You pays your money, provide your prescription, and they mail you the pills. Three, they actually gave me a price, a real discouut price, over the phone (and online too)!

        However, unless you live in the boonies or cannot get out, you can probably do considerable better than the Med Savers price with the right coupon at the right local pharmacy. Blink Health's base price for 90 sildenafil is about 40 lower than Med Savers (67.50 vs 110).

Prescription basics
Local discount pharmacies
        The consultant to the Consumer Reports article on prescription drugs said chain pharmacies price their drugs as high as possible because it increases insurance payments, which is how they make their money. That of course is bad news for erectile dysfunction drugs that are not covered by insurance. On the other hand the consultant said discount pharmacies price their drugs as low as they can and still make a fair profit.

Bye-bye Target
       I checked out a few of the discount stores in my area that GoodRx includes: Target, Kmart and Walmart. Bad news here. My first choice was Target because it's closest, but its discount pharmacy is gone. Target pharmacies were just bought by CVS and will be rebranded as CVS. The people who run Target have a long description on their web site of what the change will mean to customers, yet they somehow 'forget' to mention what the change means for drug prices, but I can guess. There's a Kmart in my area too, but their web site says it doesn't have a pharmacy, in fact only three Kmarts in MA have a pharmacy, none close. That leaves my local Walmart, which does have a pharmacy, but their prices tend not to be as good, their Revatio is 114 vs 76 Kmart and 58 online..

(update)
       When I discovered the MA drug price search tool, what's a discount pharmacy (at least for Revatio) took on a different perspective. For example, my local Walgreens is shown with a good price, lower than discount Walmart. Prescription drug pricing is a zoo, you just have to play the game to get a good price.

        The GoodRx site recommends when going to a new pharmacy that you have the new pharmacy 'pull' the prescription from your old pharmacy. This makes sense to me, the new pharmacy wants your business, so they are willing to do a little extra work to make a sale. If it's a refill at a new pharmacy, bring your old bottle, that's all they need.

Prescription security
        With my printed Revatio prescription in hand I am learning about prescription security. Not wanting to carry the prescription around I made a copy of it, but noticed on the copy the first letter of each line was partially cut off. Looking at the prescription closely under light I see that it is not printed on regular paper. The two side margins contain a (color) security device that apparently confuses copiers, and in faint print it notes the paper has a host of other security devices like a watermark and micro-printing. In a high resolution color scan I find a light green 'VOID' scattered across the paper. Haven't researched this yet, but the odds are high that a pharmacy is not going to accept a copy of a printed prescription even though it contains the doctor's info and signature. (Yup)

Does my prescription cover generics?
        My printed prescription for Revatio has this printed text: "Interchange is mandated unless the practitioner writes the words 'No Substitution' in the space above." Not sure what this means, but I hope it  means that a generic substitution is not only allowed, but 'mandated'. (Yup)

"Interchange is mandated"
        What's with the gobblegook 'interchange is mandated'. Why can't the medical community speak english? Turns out this is legal gobblegook. A google search shows this phase is mandated by MA state law! Here's the key paragraph from the MA General Laws: CHAPTER 112, Section 12D):

        "The standards shall permit the practitioner to instruct the pharmacist to dispense a brand name drug product by indicating ''no substitution''. The standards shall require that the indication of ''no substitution'' shall not be the default indication and further that the prescription indicate the ''Interchange is mandated unless the practitioner indicates 'no substitution' in accordance with the law''. Where the practitioner has so indicated ''no substitution'', the pharmacist shall dispense the exact drug product as indicated by the practitioner.

        Except in cases where the practitioner has indicated ''no substitution'', the pharmacist shall dispense: an interchangeable abuse deterrent product if one exists; or, if none exists, a less expensive, reasonably available, interchangeable drug product as allowed by the most current formulary or supplement thereof. " (Wow, you may get 'an interchangeable abuse deterrent product'! Just pile on the confusion. Turns out this is a special case for drugs subject to abuse.)

        My translation of this is that when a prescription does not specify 'no substitution', a MA pharmacist is required to dispense a generic ("less expensive, reasonably available, interchangeable drug product")

        Under 'Drugs Related by Class' (to Revatio) on the CVS site the useful chart below comes up. It shows that generics have about 80% of the market for sildenafil citrate. At the bottom it names Revatio's generic drug: Sildenafil Oral Tablet. So this is a way to find generics on the CVS site.

Visit to my local CVS (12/24/15)
        Armed with the knowledge about about Revatio and sildenafil from the CVS web site, I dropped into my local CVS to ask a few questions of the pharmacist. This was an early visit just for information, I didn't bring my prescription or any coupons. Here's the answers I got:

        * Can a copy of the prescription be used?              No,   we need to see the original  (no surprise here)
        * Can the prescription be trimmed?                        Yes     (it's on 8.5 x 11 which is mostly blank, and it looks like a trimmed version
                                                                                                           would still have security features preserved)
       * My prescription for Revatio says
              'interchange mandated', does that
               mean it also covers generic sildenafil?             Yes
       * Is it covered by Medicare part D?                        Only with 'prior approval' (PA)    (Cigna formulary says that PA may be required)
                                                                                                      Cigna formulary (2015) includes sildenafil, but not Revatio
       * I ask him to explain PA                                        Doctor needs to write a letter, which the insurance company reviews, explaining why the
                                                                                                      drug is medical required.  (This is likely an effort to avoid paying for off label usage.)
       * Do all these discount coupons work?                  Yes, but can be used only when insurance is not used (I knew this). He said my record showed
                                                                                                      I had a MA drug discount card, which he implied acted like other discount cards. (Not
                                                                                                      only did I not know I had a MA drug discount card, this was the first I had ever heard of it.)

       * What's the cost with the MA discount card?        Price quoted was so ridiculously high, my memory didn't record the details, but it was something
                                                                                              like $330 for 30 pills. I told him that price was absurd as I could buy 90 pills online from
                                                                                              a US registered pharmacy for $58. (He might have said, or meant, 90 pills, though my memory
                                                                                              is he said 30, because GoodRx shows the price of 90 generic sildenafil at CVS to be $301.)
      * Is that the CVS price for the generic?                    Yes

Qualifying for part D coverage
        I read that Revatio is usually covered by Medicare Part D, but note this was on a pulmonary hypertension site. It slowly dawned on me that this could made the price of Revatio reasonable for me even at a local pharmacy. The reason is that I take 10k worth of cancer drugs per month, so from Feb to Dec my drug cost are only 5% of the retail price (Part D 'catastrophic coverage'). I'm thinking my best chance to get Part D coverage is to say (if asked) that the Revatio prescription is related to my cancer (multiple myeloma), which is at least in part true. (nobody is going to ask)

        I suspect the insurance companies are onto the Viagra to Revatio switch. Probably to avoid paying for Revatio that is to be used off-label insurance companies (may) require 'prior approval' before they will pay. I know my insurance company (Cigna) does. A pharmacist explained to me that this requirement means your doctor has to send a letter to the insurance company explaining why the drug is medically necessary. Revatio is FDA approved only to open tiny blood vessels in the lungs lowering pulmonary blood pressure, so almost for sure this is the only medical reason the insurance companies are going to accept.

        As I see it, my doctor did me a favor in changing my Viagra prescription to Revatio knowing Revatio was to be used off-label for erectile dysfunction. I was not about to ask him to lie to say I had pulmonary hypertension.

Backstory on why no erectile dysfunction insurance coverage
        The reason government's Medicare drug program, Part D, doesn't cover erectile dysfunction drugs is that congress forbids it. The 2005 New York Times article below describes the vote, led by republicans of course.

        "We provide drugs through Medicare and Medicaid that are lifesaving drugs; we don't pay for lifestyle drugs," said Representative Steve King, Republican of Iowa, the chief sponsor of the measure. Mr. King said it was wrong to tell taxpayers that "we're going to take the money you earned on overtime to pay for Grandpa's Viagra."

Basic data on four erectile dysfunction drugs
 

Response curves
        The effectiveness of this class of drugs depends on how long the concentration of the drug remains high in the blood. This is shown by a curve which I captured from the physician prescribing document of each drug and also by a parameter called the 'biological half life'. The peak level in the blood for a particular drug depends on the dose (see Cialis sheet). The vertical units on the response curves are all equivalent (ug/L = ng/mL). It's curious how the blood concentration varies from drug to drug: Levitra peaks at 18 ug/L, Cialis and Viagra at 350-450 ug/L, and the newer and faster acting Stendra at 2,500 ug/L. The important difference between the drugs is in the time scale. Notice how much more slowly the concentration of (the longer lasting) Cialis drops compared to the other three drugs.

        The last curve is for the newer Stendra (max 200 mg dose and 1/4th 50 mg dose). Stendra's claim to fame is that it is absorbed a little more quickly than the other drugs. Two thirds of participants were able to engage in sexual activity within 15 minutes says Wikipedia (stendra).

Grapefruit trick
        I saw in the detail sheet of Viagra that it has an interaction with grapefruit juice. Apparently grapefruit just has an unusual component that affects certain drugs. I remember reading a front page story in the NYT a few years ago about how a cancer patient almost died because drinking grapefruit juice had caused the effective dose of her cancer medication to be much higher than usual. That was a little scary because I like grapefruit juice and drink some every morning, so I googled 'Viagra and grapefruit juice' and found a medical paper (link below) on test that had been run.

        The paper shows the effect of grapefruit juice on sildenafil is small, but perhaps useful. All grapefruit juice does is increase the area under the response curve by about 25%, principally by slowing the decay time. It didn't change the peak level in the plasma, but it did to some extent delay the time to reach the peak. In other words it modestly extends the time the drug is effective at the penalty of it taking a little longer for it to become effective.

         http://www.ncbi.nlm.nih.gov/pubmed/11823754

Viagra ? Revatio ingredients compared
        Here is the ingredient list I copied and pasted from the Pfizer physician prescribing documents for its two sildenafil citrate drugs: Viagra and Revatio. The only ingredient difference is at the very end of the inactive ingredient list and relates to the color, coating, and marking of the pills. Under 'IMPORTANT SAFETY INFORMATION' on the Pfizer www.revatio.com site it says, "REVATIO contains the same medicine as VIAGRA® (sildenafil), which is used to treat erectile dysfunction (impotence)", and it includes this warning, "Erections that last for more than four hours may occur with all drugs in this class." On the Revatio prescribing document physicians are advised to inform patients "that sildenafil is also marketed as VIAGRA for erectile dysfunction."

Viagra ingredients
       "Sildenafil citrate is a white to off-white crystalline powder with a solubility of 3.5 mg/mL in water and a molecular weight of 666.7. In addition to the active ingredient, sildenafil citrate, each tablet contains the following inactive ingredients: microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hypromellose, titanium dioxide, lactose, triacetin, and FD ? C Blue #2 aluminium lake."

Revatio ingredients
        "Sildenafil citrate is a white to off-white crystalline powder with a solubility of 3.5 mg/mL in water and a molecular weight of 666.7.  In addition to the active ingredient, sildenafil citrate, each tablet contains the following inactive ingredients: microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hypromellose, titanium dioxide, lactose monohydrate, and triacetin."

Researching Indian generics manufacturers
        I used the images above as a starting point to research Indian manufacturers who make erectile dysfunction drugs. These three manufacturers all have Wikipedia pages that describe the size of the company. From the home page of Ajanta Pharma Limited I learned that their Viagra generic, sold under their brand name Kamagra, has been approved for sale as a generic in the EU, that's a real plus. From the Cipla site I learned that they have FDA approval for a few of their generics. When I searched Cipla Assurans, I came up with the link below that list dozens and dozens of sildenafil manuf and the brand name they sell under.

        http://www.drugsupdate.com/brand/generic/Sildenafil/40778/3

        Here's a short article from the New York Times (2/9/16) on the crazy quilt pattern of retail prescription drug prices and how to fight back with two price search sites: GoodRx and a new one formed after I wrote this essay called 'Blink Health'  -- https://www.blinkhealth.com/.

         http://www.nytimes.com/2016/02/10/business/taming-drug-prices-by-pulling-back-the-curtain-online.html

        From the title I was hoping this would be a good addition to the literature, but it's pretty thin. Erectile dysfunction drugs, the poster child for expensive drugs not covered by insurance, are not even mentioned. It does make a couple of good points. The GoodRx founder says, "99% of the world doesn't know there is any way to look up a (drug) price", and I bet he's right. The article says GoodRx and Blink Health get their prices from pharmacy benefit managers. GoodRx working with several and Blink Health associated with MedImpact.

        At a recent congressional hearing on drug prices "Peter Welch, Democrat of Vermont, directed an exasperated question at an executive of Turing Pharmaceuticals, which set off public outrage last fall after sharply raising prices on a little-known drug. “Why isn’t it possible,” he asked, “to just have a price where anybody who wants to know what that price is can go to a website and see?”  I think my essay pretty much answers that question. It's not in the pharmacies interest to do so, so they don't. A labyrinthine, convoluted system full of traps for the unwary has evolved allowing the pharmacies to charge the occasional buyer, the trusting buyer, and all but the most dedicated price shopper a price far, far higher than the 'real' price of a drug, which is, of course, the price the insurance companies and pharmacy benefit managers pay.