# Cost comparison of phosphodiesterase type 5 inhibitors: rural vs urban New York State counties and online pharmacies

## TL;DR

This study compares the cost of erectile dysfunction medications in rural and urban New York counties and online pharmacies.

## Contribution

It is the first to examine PDE5 inhibitor pricing in rural populations and compare small vs. large pharmacy chains.

## Key findings

- Small chain pharmacies had lower prices than large chains for PDE5 inhibitors.
- Online pharmacies showed the most price variability for the drugs.
- Rural counties had different demographic characteristics compared to urban areas.

## Abstract

Phosphodiesterase type 5 (PDE5) inhibitors are used to treat erectile dysfunction, but their cost can limit access.

This study examines PDE5 inhibitors pricing and demographic data across rural and urban New York State (NYS) counties, as well as small, large, and online pharmacies.

Prices from 133 chain pharmacies were collected from 15 randomly selected urban and 15 rural NYS counties. Counties without at least two large chain pharmacies were excluded. Data included small chains (n = 49), large chains (n = 84), rural (n = 57), urban (n = 76), and online pharmacies (n = 12). Prices for 20 tablets of sildenafil (100 mg) and tadalafil (20 mg) were gathered using GoodRx standard coupons. Price per unit for online pharmacies was calculated for quantities closest to 20 pills. Demographic data was sourced from the U.S. Census Bureau. This study was considered exempt from IRB review. Statistical analyses including t-tests, Wilcoxon rank-sum, and Kruskal–Wallis tests were performed using R Version 4.4.1 (2024-06-14).

The cash price of the PDE5 inhibitors across various pharmacy chain types and county types.

Prices were lower in small chain pharmacies compared to larger chains (P < .001), but did not significantly differ between rural and urban counties (P > .6). Small chain rural pharmacies were cheaper than urban counterparts for sildenafil (P = .032). Online pharmacies offered the lowest and highest prices, with significant differences by chain type (P < .001) but not by county type (P > .100) for both drugs. Rural counties had a smaller Native Hawaiian (P = .001), Asian, Black/African American population and a larger White (P < .001) and American Indian population (P = .031). Median income was higher in urban counties (P = .010), but the percentage of the population without health insurance coverage did not differ (P = .177).

This study aims to highlight the pricing variability of PDE5 inhibitors to help patients identify cost-effective options to circumvent potential financial barriers.

This study was the first to examine PDE5 inhibitors pricing specifically within rural populations while also providing a comparative analysis of pricing differences between small and large pharmacy chains serving these communities. The study’s limitations include a relatively small sample size of rural and small chain pharmacies resulting in power levels of 75% and 69%, respectively, which may impact the generalizability of the findings.

Enhancing drug price transparency for PDE5 inhibitors is vital for increasing access and pricing flexibility.