That's when the world shifted for patients. From December 2017 to June 2021, the list price for six tablets of 100 mg of generic sildenafil (the most common prescribed amount) fell by 98% from $265 to $4, according to an analysis provided by GoodRx.com. Over that same time, the average list price for the equivalent doses of Viagra grew by 27% from $369 to $467. "We're still seeing spikes with Viagra every year, while sildenafil has plummeted in price," GoodRx.com director of research Tori Marsh, MPH, told MedPage Today. "I have no idea why there continues to be that large price gap. There is just no good reason," endocrinologist Bradley Anawalt, MD, chief of medicine at the University of Washington Medical Center, told MedPage Today. Markups for brand-name drugs facing generic pressure aren't a new phenomenon. "The idea is that once a generic enters the market, the prices of the generic go so low in comparison with the brand that it doesn't make sense for the brand to compete based on price," Seoane-Vazquez said.

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"Companies can decide the price of drugs in the U.S. private sector without any constraints," Enrique Seoane-Vazquez, PhD, a professor of pharmacy who studies drug pricing at Chapman University in Irvine, California, said in an interview with MedPage Today. "We may need public health campaigns explaining the value of generic drugs so patients have information and can decide if they want to expend thousands of dollars out-of-pocket to get the brand drug instead of the low-cost generic." Viagra: Still the ED Leader After All These Years Sildenafil entered the U.S. market as Viagra in 1998 and instantly revolutionized impotence care by giving men a convenient alternative to less-than-appealing erectile dysfunction (ED) treatments like penis pumps, injections, and implants. The little blue pill became a household name thanks to celebrity endorsements, TV commercials, and the world's most famous side effect. This is why shelves are filled with competing over-the-counter products that are essentially the same except one costs more and has a familiar name attached -- Bayer, Tylenol, Afrin, Metamucil. On grocery shelves, the big difference from pharmaceuticals is that no one requires low-priced supermarket brands to taste the same as Ragu pasta sauce or Kellogg's Corn Flakes.

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But equivalent brand-name Viagra pills cost at least $67.12 each, or $2,013.70 for 30. That's a remarkable markup of over 150 times the generic price, even though the pills share the same active ingredient and work the exact same way. A MedPage Today investigation found that Viagra is perhaps the most extraordinary example of a curious phenomenon in the world of drug pricing -- brand-name medications whose prices go up despite the arrival of stiff competition from much-cheaper generics. This isn't the way competition in capitalism is supposed to work, and it's hardly healthy for consumers. But some pharmaceutical companies are banking big-time on brand-name loyalty and ignorance about generics, and no one is going to tell them to knock it off. In contrast, equivalent brand-name and generic drugs are mandated by law to be identical -- mostly. As the FDA puts it, "a generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used." There are some differences: Brand-name drugs may have different inactive ingredients than the equivalent generics, and they typically look different due to trademarks that protect their appearance. Among sildenafil pills, for example, only brand-name Viagra can be both blue and diamond-shaped.

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However, Kezzler introduced QR and Datamatrix codes to the package design, allowing consumers to use a smartphone to verify authenticity in a matter of seconds. “A well-executed serialization program provides effective protection, especially when it arms the patient with a very powerful tool that enables them to authenticate their product directly and in real-time,” says Akselsen. “Following rollout, customers can place their trust in three parties: Pfizer, the Kezzler system, and themselves by inspecting the product directly.” Kezzler’s rapid response led to a substantial increase in sales of the authentic Viagra, according to Kezzler. This project launched in 2012 and has since expanded to several more products and countries in Asia, for which the Pfizer team also won a Commercial Innovation Award. Currently, Kezzler has integrated their online system with point of sales systems at pharmacies in Hong Kong so that every sale is now reported and documented for Pfizer. There can also be variations in the bioavailability of a drug's active ingredient. It's not easy to understand exactly how much the typical customer pays for brand-name and generic sildenafil. For one thing, list prices don't truly represent the amount that customers pay for drugs. Pharmacies discount the prices of medications, and consumers can get coupons from a variety of sources such as pharmaceutical companies and GoodRx.com.

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(Sorry, gentlemen, a four-hour erection isn't all it's cracked up to be.) Nearly a quarter-century later, sildenafil has spawned a handful of competitors, notably tadalafil (Cialis) and vardenafil (Levitra), but it remains the undisputed king of ED care in the U.S., according to 2018 to 2019 numbers. "Viagra is still often the first drug prescribed because everyone knows about it, and even primary care docs are comfortable writing it. Also, the evidence in the literature largely supports it being the strongest and most efficacious" of the main ED drugs, University of Utah urologist Alexander Pastuszak, MD, PhD, told MedPage Today. "There are strong considerations for Cialis as well, but it's less popular because fewer physicians and patients really know how to use it." Patent expiration, the perennial scourge of brand-name drug manufacturers, came for Viagra in the late 2010s. Pfizer and Teva Pharmaceuticals began selling generic forms of sildenafil in late 2017, and other companies started offering generic products the following year. To make things even more complicated, insurers may not cover ED drugs, and even if they do they're not likely to pay for expensive brand names when generics are available. One thing is clear: Viagra's markup is consistently high. According to GoodRx.com, the cheapest price in the San Diego area for six tablets of 100 mg generic sildenafil is $9.47 at Ralphs supermarkets with a free coupon. The least expensive price for the equivalent amount of brand-name Viagra is $404.26 at all 10 pharmacy outlets listed with a free discount -- a markup of 42 times. When It Comes to Humongous Markups, Viagra Stands Tall Viagra isn't alone in boosting its price in response to competition. For nearly 3 decades, researchers have chronicled the "generic competition paradox": Drugmakers actually boost the prices of their brand-name medications when cheaper generics enter the market. The most likely brand-name drugs to do this are those with high name recognition and intense generic competition, Seoane-Vazquez said. (Viagra fits this description.) Other types of drugs are less likely to raise their prices in response to generics. These, he said, include drugs such as biologics with limited competition, drugs used in hospitals and physician offices, and drugs with relatively low name recognition such as some antibiotics. In a bit of good news for consumers, the generic competition paradox phenomenon appears to be less common than it used to be, according to researchers with StoneTurn, a consulting firm. They examined 78 drugs whose patents expired from 2009 to 2020 and found that their prices tend to stabilize after generic equivalents appear and not go up at a fast clip.

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In a weird paradox, it's never been cheaper -- and more expensive -- for men to treat themselves with sildenafil (Viagra), the mainstay of erectile-dysfunction therapy. And herein lies a tale about the bizarro world of drug pricing. Generic versions of sildenafil cost as little as 44 cents per typical 50-mg dose in the U.S. when 30 pills are purchased, according to GoodRx.com. At that price, the doses needed to power a month's worth of daily intimate encounters add up to just $13.20, less than a Chipotle steak burrito with guacamole and a drink. This marks a significant shift from the past, the researchers argue in a 2021 study published in the International Journal of the Economics of Business. They write: "We believe the results in our paper reflect the brand-name pharmaceutical companies' acknowledgement of the ever-changing competitive landscape and their attempt to moderate price increases in response to the ever-growing market presence of generics." "Its price did keep moving up even after the generic entry, with the annualized rate of change at 9.5% before generic entry and 15.4% afterwards," study co-author Yong Xu, a managing director at StoneTurn, told MedPage Today. The price markup of Viagra since it gained generic competition appears to be an outlier among ED drugs specifically and prescription drugs in general. Thirty tablets of a typical 5-mg dose of tadalafil, for example, cost as little as $11.05 in the generic form but jumps to at least $365.51 as brand-name Cialis, per GoodRx.com.

Comparing Drug Interactions

“Aggregation for track and trace is the next level, but in this case a quick and fast solution to tackle the problem of counterfeit Viagra led to the prioritization of the serialization solution,” says Christine C. Akselsen, CEO of Kezzler. Kezzler applied both visible and non-visible codes, which were unique, secure, and traceable, to each pack of Viagra at the distribution centers, avoiding packaging lines completely to speed the serialization process. Full implementation took place within a few weeks of the printing and approval of the first batch of labels. The codes enabled consumers, Pfizer, and other supply chain stakeholders to verify every pack’s authenticity with a scanner, but a major challenge was educating consumers on how to use the new security feature.