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Research Paper
JPHSR 2012, 3: 103–107
© 2012 The Authors
JPHSR © 2012 Royal
Pharmaceutical Society
Received November 16, 2011
Accepted November 17, 2011
DOI
10.1111/j.1759-8893.2011.00080.x
ISSN 1759-8885
Correspondence: Mohamed
Azmi Hassali, Discipline of Social
and Administrative Pharmacy,
School of Pharmaceutical
Sciences, Universiti Sains
Malaysia, Penang, Malaysia.
E-mail: azmihassali@usm.my
A study comparing the retail drug prices between Northern
Malaysia and Australia jphs_80 103..107
Mohamed Azmi Hassalia, Asrul Akmal Shafiea,
Zaheer-Ud-Din Babarb and Tahir Mehmood Khanc
a
Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains
Malaysia, Penang, Malaysia, bSchool of Pharmacy, Faculty of Medical & Health Sciences, The University of
Auckland, Auckland, New Zealand and cDepartment of Pharmacy Practice, College of Clinical Pharmacy,
King Faisal University, Alahsah, Kingdom of Saudi Arabia
Downloaded from https://academic.oup.com/jphsr/article/3/2/103/6096403 by guest on 02 July 2023
Abstract
Objectives The current study aims to compare the retail prices of the 10 most prescribed
drugs in Northern Malaysia and Australia.
Methods A cross-sectional study was conducted to compare the retail prices of the 10 most
used prescription medications in Penang, Malaysia, with the retail prices of the same drugs
in Australia. Data collection was done using a standard form. Percentage difference was
calculated using simple mathematical formulae in Microsoft Excel.
Key findings Findings demonstrate that the mean retail drug prices in Penang, Malaysia,
were 30.30–148.28% higher than the mean retail prices in Australia. In addition, variation
between retail prices was also noticed between pharmacies in Penang, with a difference
between highest and lowest of 80%.
Conclusion Malaysia has average higher retail prescription drug prices compared to Aus-
tralia due to the lack of pharmaceutical market regulation, which could impose limits on
prices, profits and total spending on pharmaceuticals.
Keywords Australia; comparison; Malaysia; retail prescription price
Introduction
Prescription drug expenditures are one of the fastest growing components of national health
budgets.[1] Price is clearly one of the greatest barriers to the access to essential drugs.[2] It has
been reported that the purchase of medicines contributes significantly to the healthcare
budget of developing countries and that drug expenditures may account for 50–90% of
non-personnel costs.[3] Furthermore, cost-related underuse among the non-insured popula-
tion is very common; even small increases in drug prices can dramatically affect medication
adherence among the poor.[4]
Globally different schemes are implemented to regulate drug prices; for example France
and Italy regulate drug prices directly through price control. However, Germany and Japan
maintain price control indirectly through reimbursement under social insurance schemes. In
Britain the National Pharmaceutical Pricing Authority monitors prices through the Pharma-
ceutical Price Regulation Scheme, which controls the prices of branded prescription medi-
cines by regulating the profits that companies can make on sales.[5]
Conversely, the Malaysian health sector lacks pricing control, and a ‘price deregulation
system’ is employed in which manufacturers, distributors and retailers set medicine prices
without government interference. Indeed, due to deficient price control medicine prices in
Malaysia have been reported to be escalating even faster than in the developed world.[6–8] In
the private health sector drug prices are considerably higher because doctors are allowed to
dispense and prescribe medicines and they tend to charge higher mark-ups. Furthermore,
mark-ups are also known to be higher in the pharmaceutical supply chain, contributing to
high drug prices overall.[9]
In addition to price deregulation, which occurred in 1994, the Malaysian government
has approved a privatized drug-distribution system for public health care facility. It was
believed that this system would help to reduce administrative and financial burdens and
would ensure an efficient healthcare sector and facilitate the economic growth.[10] Unfortu-
nately, the predictions for this ‘free market economy’ went wrong and immediately after the
103
104 Journal of Pharmaceutical Health Services Research
privatization of the distribution system a substantial increase
of about 3.3-fold was observed in medicine costs.[11] Recent
studies confirm the sustained increasing trends in the price of
certain essential medicines like anti-infective and cardiovas-
cular agents.[5,7,8] Perhaps in the public sector the variation in
prices can be controllable because the chain of command is
managed by the Malaysian Ministry of Health. However, due
to the occasional scarcity of medicines that sometimes occurs
and the long waiting hours at public outlets many people
prefer to seek health care from dispensing doctors or private
hospitals.[12] It is evident that in the private sector (i.e. private
hospitals, clinics, physician-operated dispensaries and com-
munity pharmacies) there are major variations in drug prices.
It is woeful to see that many generic medicines were found to
be more costly at clinics run by dispensing doctors when
compared with the price of the drugs at local pharmacies.[5] In
spite of these documented cases, it is distressing to see that
Malaysian government authorities and the pharmaceutical
industry claim that medicine prices in Malaysia are reason-
able. It remains a mystery why the authorities are not willing
to acknowledge the price differences, which are mainly due to
the lack of a pricing policy. Previous studies focusing on the
cost of medicines in Malaysia have made the comparison at
the national level only. So far, no price comparison has been
made with developed nations that have implemented a pricing
policy. It can be assumed that, if made, such comparisons
would be helpful in drawing the attention of the authorities to
this critical issue in healthcare costs.
The current study compared Malaysian drug prices with
those of a developed nation, Australia. However, both coun-
tries have different health and economic indicators and gross
national product (GNP) per capita, but the preliminary data
will be helpful to see the price disparities. This study aims to
compare the retail prices of the 10 most prescribed medicines
between Malaysia and Australia. This will be the first study to
draw the attention of the Malaysian government authorities
and pharmaceutical industry to the retail price differences
between countries which do have a drug policy and those
which do not have one.
Method
A comparative study was planned to calculate the percentage
price differences in retail prices of the 10 most utilized medi-
cines in Malaysia with the prices of similar products in Aus-
tralia. Three main areas were defined in Penang State (a state
in Northern Malaysia): Bukit Jambul, Pekaka and Bayan
Lepas. Twenty-five pharmacies were approached by conve-
nience sampling from these three places. Of these, five were
dropped because the pharmacist was not willing to share the
actual retail prices of medicines.
The retail selling prices in Australia were obtained online,
by taking the average selling prices of the three most famous
retail pharmacy chain stores in Australia; that is, Chemist
Warehouse, Terry White Chemist and My Chemist. Chemist
Warehouse is the largest pharmacy retailer in Australia while
Terry White Chemist is an Australian-owned pharmacy group
with over 150 franchises.[13,14] My Chemist is a group of inde-
pendent pharmacies with over 40 stores in Victoria, New
South Wales and South Australia.[15]
2012; 3: 103–107
Table 1 Drug category based on indication and poison schedule
Drug category Drugs investigated Poison list
in this study
1 Analgesic (non-steroidal Diclofenac Group C
anti-inflammatory drugs)
2 Anti-asthmatic agent Salbutamol Group C
3 Antidiabetic agent Metformin Group C
Gliclazide Group C
4 b-Blocker agent Atenolol Group B
Metoprolol
5 Calcium-channel blocker Amlodipine Group B
Nifedipine Group B
6 Dyslipidaemic agent Atorvastatin Group B
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Simvastatin Group B
In Australia, there are four types of price available for
prescription products: Private, National Health Scheme, Con-
cession and Safety Net. The Private and National Health
Scheme prices are open to the public and customers can
choose whichever prices suit them best. However, Concession
and Safety Net require one to have the appropriate entitlement
cards to qualify for the marked price. Based on the present
health scheme in Australia, the prices of all prescriptions are
listed as Pharmaceutical Benefits Scheme (PBS) prices. These
prices are set by the government and under current legislation
cannot be discounted. If the price does not appear in the PBS
field, the prescription is only available as a Private prescrip-
tion. Private prescriptions are those not subsidized by the
government, leaving the patient to pay the full price for the
prescribed item.[13]
To ensure the uniformity of the data a standard data-
collection form was designed. The entire range of data in
each case (i.e. brand name, company name, dose strength
and retail selling prices) was considered to make the com-
parison. The medicines included in the study were divided
into groups based on their indication and poison schedule
(Table 1).
The medicines that were included in the study are listed in
Table 2. The differences in retail prices between Malaysia and
Australia are stated in terms of percentage per unit dose.
Results
The mean retail prices per dose of 10 out of the top 20 most
purchased drugs in Malaysia were compared with the mean
prices per dose of three large retail pharmacy stores in Aus-
tralia. The prescription drug prices were collected from 20
retail pharmacies in Penang while the retail prescription drug
prices of Australia were obtained online.
Comparison based on the mean price difference revealed
that retail price of the selected medicines in Malaysia were
higher than the retail price in Australia. The lowest mean
price percentage difference noted was 30.30% for Noten®
(atenolol) 50 mg tablet and the highest was 148.28% for
Betaloc® (metoprolol) 50 mg tablet. Detials about the com-
parative percentage differences are shown in Table 2.
Furthermore, standard deviations and mean and median
retail prices of the 20 selected pharmacies in the state of
Drug prices in Malaysia and Australia Mohamed A. Hassali et al. 105

Table 2 Retail prescription drugs price differences between Australia and Malaysia

Brands (prescription drugs) Number of Mean retail Malaysian price relative Manufacturer
retail pharmacies price per dose* to Australian price
in Penang selling MYR AUS Price difference % Difference (Malaysia
the drug
(in MYR) compared with Australia)

1 Norvasc® (amlodipine) 10 mg 20 3.34 2.17 1.17 +53.91 Pfizer

tablet
2 Lipitor® (atorvastatin) 20 mg 19 5.07 3.12 1.95 +62.50 Pfizer
tablet
3 Glucovance® (metformin+ 16 0.79 0.38 0.41 +107.89 Merck Serono
glyburide) 500/5 mg tablet
4 Diamicron® (gliclazide) 80 mg 17 0.91 0.48 0.43 +89.58 Servier
tablet

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5 Noten® (atenolol) 50 mg tablet 18 0.86 0.66 0.20 +30.30 Alphapharm/Merck
6 Ventolin® nebuliser (salbutamol) 7 4.31 2.29 2.02 +88.21 GlaxoSmithKline
2.5 mg dose
7 Voltaren® (diclofenac) 50 mg 15 1.52 1.05 0.47 +44.76 Norvatis
tablet
8 Adalat LA® (nifedipine) 60 mg 12 3.49 2.45 1.04 +42.45 Bayer HealhCare
tablet
9 Zocor® (simvastatin) 80 mg 9 4.71 3.31 1.40 +42.30 Merck Sharp and
tablet Dohme
10 Betaloc® (metoprolol) 50 mg 16 0.72 0.29 0.43 +148.28 AstraZeneca
tablet

*Conversion rates based on international exchange rate on 14 August 2010: 1 AUS=2.83042 MYR.

Table 3 Comparison of retail prescription drug prices in Malaysia

Brands (prescription drugs) Maximum price Median price Minimum price Mean price Standard
per dose (MYR) per dose (MYR) per dose (MYR) per dose (MYR) Deviation (SD)

1 Norvasc® (amlodipine) 10 mg tablet 8.67 2.82 1.60 3.34 1.76

2 Lipitor® (atorvastatin) 20 mg tablet 7.17 4.50 3.83 5.07 1.04
3 Glucovance® (metformin+glyburide) 1.39 0.78 0.53 0.79 0.23
500/5 mg tablet
4 Diamicron® (gliclazide) 80 mg tablet 1.10 0.90 0.58 0.91 0.12
5 Noten® (atenolol) 50 mg tablet 0.50 0.30 0.23 0.86 0.07
6 Ventolin® nebuliser (salbutamol) 2.5 mg dose 4.40 4.40 4.00 4.31 0.14
7 Voltaren® (diclofenac) 50 mg tablet 2.67 1.20 0.30 1.52 0.52
8 Adalat LA® (nifedipine) 60 mg tablet 4.86 3.40 2.40 3.49 0.60
9 Zocor® (simvastatin) 80 mg tablet 6.60 5.00 1.20 4.71 1.61
10 Betaloc® (metoprolol) 50 mg tablet 0.83 0.73 0.60 0.72 0.07

Penang were also calculated to see the possible retail price
differences between the pharmacies in Penang (Table 3). The
price of calcium-channel blocker Norvasc® (amlodipine) was
highly variable within Penang (MYR3.34⫾1.76). Interest-
ingly, other antihypertensive medicines (i.e. Noten and
Betaloc) were found to be less variable in terms of retail price
(SD ⫾0.07). It was also noticed that for some drugs the price
of a unit dose was exceptionally high. The highest retail
mark-up price for Norvasc was MYR8.67 per 10 mg tablet,
and for Lipitor® (atorvastatin) the highest price was
MYR7.17 per 20 mg tablet. See Table 3.
Moreover, to see the price variation for the selected drugs
in the state of Penang, mean prices were compared among the
three regions (Bukit Jambul, Pekaka and Bayan Lepas) from
which the pharmacies were selected for data collection.
Overall, every region has its own prices. However, the
mark-up price for the Bukit Jambul region was found to be
higher than for the pharmacies in other regions. Details about
the price variation of the selected medicines in the three
regions are given in Table 4.
Discussion
This was perhaps the first study in Malaysia to compare the
price of medicines with those in a developed country. In
Malaysia, drug prices vary across the country. As there is a
lack of generic medicines on the National Essential Drug List
and the Drug Formulary in the public sector, patients buy such
medicines from private sector outlets such as retail pharma-
cies. Unfortunately, due to the absence of a national drug
pricing policy it is hard for the public to get essential drugs at
the same price across the country.[16] Cross-national differ-
106 Journal of Pharmaceutical Health Services Research
Table 4 Comparison of retail mean prices among three areas in Penang
Brands (prescription drugs)
Bukit Jambul
®
Norvasc (amlodipine) 10 mg tablet
Lipitor® (atorvastatin) 20 mg tablet
Glucovance® (metformin+glyburide) 500/5 mg tablet
Diamicron® (gliclazide) 80 mg tablet
Noten® (atenolol) 50 mg tablet
Ventolin® nebuliser (salbutamol) 2.5 mg dose
Voltaren® (diclofenac) 50 mg tablet
Adalat LA® (nifedipine) 60 mg tablet
Zocor® (simvastatin) 80 mg tablet
Betaloc® (metoprolol) 50 mg tablet
ences in pharmaceutical prices are of great interest around the
world. Cross-national price comparisons for pharmaceuticals
enable policy makers to draw conclusions about differences in
average price for individual products, and allow governments
to set domestic prices.[17]
Based on the price comparison, this study reveals that
retail prescription drugs in Penang pharmacies generally
cost more than the same drugs in Australian pharmacies.
The minimum variation noted in price was 30.30%, while
the maximum was 148.28%. It has already been documented
that in Malaysian private pharmacies and in the clinics of
dispensing doctors innovator-brand drug prices were 16
times higher than the international reference drug prices
(IRP), while generic drugs were 6.6 times higher.[18] The
current results have clarified that in developed countries like
Australia drug prices are controlled for the public’s conve-
nience and in Malaysia, due to the lack of drug-pricing
control policies, people pay higher prices to gain access to
essential medicines.[8] The main reason behind this price
variation is the mark-up on the sale of medicines. Malaysian
retail pharmacies mark-up about 25–38% on innovator
brands and 100–140% on generic medicines,[19] which makes
medicine in Malaysia more expensive than in other devel-
oping countries like India and Sri Lanka. On the other hand,
the pharmacy mark-up in Australia is a paid by the Austra-
lian Government to pharmacists for supplying the medicine.
On average, the Australian mark-up varies from 4 to 15%,
which far lower than that of the Malaysian pharmacy mark-
up, which results prices variation in every community phar-
macy outlet.[20] For example, a higher price deviation was
noticed for Norvasc (amlodipine). The highest price and the
lowest price per unit dose differed by 80%. Furthermore, in
five retail pharmacies that we approached the pharmacist
was not willing to reveal the actual selling price or recom-
mended selling price of the prescription drugs. In addition,
there is no interference by the government in the sale of
medicine, allowing all manufacturers, distributors and retail
pharmacists to fix the prices for all medicines.[21,22] On the
other hand, in developed nations, due to pricing regulations
and government subsidies,[23–25] medicines are available at
affordable prices to the public.[26]
Overall, it would be appropriate to say that the concept of
‘free market economy’ in Malaysia has placed the monopoly
of medicine sales in the hands of manufacturers, distributors,
2012; 3: 103–107
Mean retail price per dose (MYR)
Pekaka Bayan Lepas
3.65 2.84 3.36
5.33 4.88 5.08
0.79 0.81 0.79
0.94 0.77 0.95
0.34 0.35 0.30
4.20 4.29 4.40
1.03 0.69 1.52
3.68 3.16 3.61
5.00 4.87 4.82
0.73 0.72 0.71
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dispensing doctors and community pharmacists. In our
current study sample it was seen that there was a major varia-
tion in price in the three regions that were selected for the
study from Penang. It was surprising to note that the variation
in the prices of medicines was mainly dependent on the pur-
chasing power of the residents. Pharmacies in Bukit Jambul
were found to sell the medicines at higher prices than the other
regions. Overall, the pharmacies in Penang were found to
have different mark-ups on individual products. Lack of
monitoring or responsibility from the government and regu-
latory authorities results in a situation where manufacturers,
distributors, dispensing doctors and community pharmacists
can sell the medicines on their desired price to maintain
normal supply and demand.[5]
Access to affordable and lower-priced medicines are
the aims of the National Medicine Policy of Malaysia. The
National Medicine Policy states that drugs shall continue to be
exempted from taxes and import duties to help maintain the
prices at the lowest possible level.[27–29] However, in the phar-
maceutical market the free market strategy alone may be
unable to control the prices in Malaysia. High drug prices
have been an issue in Malaysia since the 1980s when the
government abolished 5% surtax and 5% duty in order to
reduce the cost of drugs. However, the prices remain higher
and the issue arose again in 1990s when non-governmental
organisations acting in the public’s interest complained of
increasing drug prices.[5,30] The current drug-pricing issues
highlight the need to implement a medicine pricing policy and
a price-monitoring system in Malaysia. By doing so, the
Malaysian government can ensure access to cost-effective
treatment for its citizens.
Limitations
A small sample size is one of the major limitations of this
study. Therefore, these findings cannot be generalized for the
whole of Malaysia. Secondly, this study has only compared
brands that are manufactured by the multinational drug com-
panies. Generic medicines marketed and distributed by local
and international pharmaceutical firms can be compared with
the Australian generics to further clarify the in-depth cost
variations. Furthermore, this study has not included any dis-
count that may be given by the pharmacist to permanent
customers.
Drug prices in Malaysia and Australia
Conclusion
Drug-pricing control and subsidy by the government to phar-
macies were the two main factors resulting in low retail prices
of drugs in Australia. Overall, it is seen that due to the lack of
these two factors in Malaysia retail drug prices are higher.
Furthermore, every pharmacy has its own percentage mark-up
and prices were found to vary based on the purchasing power
of residents in Penang.
Declarations
Conflict of interest
The Author(s) declare(s) that they have no conflicts of interest
to disclose.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Acknowledgements
The authors would like to acknowledge the following third
year pharmacy students for help with the data-collection
phase: W.Y. Mak, Y.H. Ng, J.H. Ong, S.C. Wong, S.S.N. Tan,
S.K. Salleh, M.A. Hasan, M.B. Daim, N.J. Ali, O. Yahya, M.
Masrus, M.I. Nasaruddin, A.S. Baharudin, N.W.N. Rahimi
and A. Husin.
References
1. Smith C et al. Health spending growth slows in 2003. Health Aff
[Millwood] 2005; 24: 185–194.
2. Nóbrega OT et al. Retail prices of essential drugs in Brazil: an
international comparision. Rev Panam Salud Publica 2007; 22:
118–123.
3. Quick JD et al. Managing Drug Supply, 2nd edn. West Hartford,
CT: Kumarian Press, 1997: 7–9.
4. Walid FG et al. Drug prices at pharmacies: are prices higher in
poorer area? Health Serv Res 2009; 44: 606–617.
5. Babar ZU et al. Evaluating drug prices, availability, affordability,
and price components: implications for access to drugs in Malay-
sia. PLoS Med 2007; 4: 82.
6. Azmi IM, Alavi R. TRIPS, patents, technology transfer, foreign
direct investment and the pharmaceutical industry in Malaysia. J
World Intellect Property 2001; 4: 947–974.
7. Babar ZU et al. Effect of privatization of the drug distribution
system on the prices of anti-infectives in Malaysia. J Pharm
Finance Econ Policy 2004; 13: 3–26.
8. Babar ZU et al. A pricing analysis of cardiovascular and blood
products after privatization of drug distribution system in Malay-
sia. J Pharm Finance Econ Policy 2005; 14: 3–25.
9. Hill SR. Medicine prices and Malaysia- untangling the medi-
cines web. PLoS Med 2007; 4: 149.
10. Balasubramaniam K. Structural adjustment programs and priva-
tisation of health care services: prospects and problems for
Mohamed A. Hassali et al. 107
health for all-now. Privatisation, Quality & Rights Proceedings
of the Asia Pacific Consultation on Quality of Health Care Ser-
vices; Madurai, India, 11–14 December 1996: 4–33.
11. Izham M et al. Drug distribution system in Malaysia: the priva-
tization of the general medical Store. National Conference on
Privatization & Health Care Financing in Malaysia; Penang,
Malaysia; 5–6 April 1997.
12. Moe S, Khin Saw Naing D. Health care financing: consumers’
perspectives. Arch Pharm Pract 2011; 2: 47–49.
13. Chemist Warehouse. Chemist Warehouse profile. www.
chemistwarehouse.com.au/aboutus/prescriptions.asp (accessed
28 August 2010).
14. Terry White Chemists. Terry White Chemists profile. www.
terrywhitechemists.com.au/about-us (accessed 28 August 2010).
15. Mychemist Group. Mychemist Group profile 2008.
Downloaded from https://academic.oup.com/jphsr/article/3/2/103/6096403 by guest on 02 July 2023
www.mychemist.com.au/company-profile/default.aspx?none
(accessed 28 August 2008).
16. Hassali MA, Shafie AA. Price comparison between innovator
and generic medicines sold by community pharmacies in the
state of Penang, Malaysia. J Generic Med 2008; 6: 35–42.
17. Patricia MD, Jeong DK. International price comparisons for
pharmaceuticals. Pharmacoeconomics 1998; 14: 115–128.
18. Babar ZU et al. A survey of medicine prices in Malaysia by using
WHO/HAI methodology. Research Report. Penang, Malaysia:
UCSI-USM, 2005.
19. Consumer Association of Penang. High Cost of Medical Care.
The Money Book. Penang: Consumer Association of Penang,
2004: 184–185.
20. Australian Government Medicare Australia. Pharmacy mark-up.
2010. www.medicareaustralia.gov.au/provider/pbs/pharmacists/
pricing.jsp (accessed 28 August 2010).
21. Kolassa EM. Prices politic, and problems – a pricing philosophy.
J Pharm Mark Pract 1997; 1: 21–27.
22. Mahmood M, Bukhari NI. Pharmaceutical Management and
Marketing. Faisalabad: Tariq Academy, 2002: 115–144.
23. Wertheimer AI, Grumer SK. Overview of international phar-
macy pricing. Pharmacoeconomics 1992; 2: 449–455.
24. Danzon PM. Making sense of drug prices. Regulation 2000; 23:
56–63.
25. Australian Government Productivity Commission. International
pharmaceutical price differences, research report. Australian
Government Productivity Commission, Canberra 2001. www.
pc.gov.au/study/pbsprices/finalreport/pbsprices.pdf (accessed 20
August 2010).
26. Bloor K et al. Lessons from international experience in control-
ling pharmaceutical expenditures III: regulating industry. Br
Med J 1996; 313: 33–35.
27. Ministry of Health (Malaysia): Pharmaceutical Services Divi-
sion. National medicine policy. Ministry of Health (Malaysia):
Pharmaceutical Services Division, 2009; 7: 1–24.
28. Danzon PM, Furukawa MF. Prices and availability of pharma-
ceuticals: evidence from nine countries. Health Aff [Millwood]
2003; 22: 521–536.
29. Danzon PM, Kim JD. International price comparisons for phar-
maceuticals: Measurement and policy issue. Pharmacoeconom-
ics 1998; 1: 115–128.
30. Richard GF. Prescription drug prices: why do some pay more
than others do? Health Aff [Millwood] 2001; 20: 115–128.