A visit to Portugal gives a patient new perspective on how pharmaceutical costs in the U.S. are out of step with the rest of the world and the impact it has on the care physicians can deliver.
The Airbnb in Portugal looked quaint. Its blue door stood out on a narrow cobblestone street and, with the listing highlighting that it was near the water, visions of walking to a sandy beach awaited.
Although it turned out to be closer to the local Staples than to Portimäo's wide sandy beaches and that it had one small window, two odd sections of glass floor in the bedroom loft and steps that meant you were taking your life in your hands heading to the bathroom in the dark of night, it still had a silver lining. Just a few steps around the corner was the Farmácia do Rio, its green cross sign brightly announcing that it was open late.
Earlier in the year I had been prescribed Eliquis (apixaban), an anti-coagulant, due to a couple of unfortunate events. Even more unfortunate, I learned as I transitioned to Medicare in April, was that one of the country’s most popular prescriptions was $500 or more for just a 30-day supply on my $8 per month Part D drug plan. It had been a $55 co-pay on my previous Blue Shield plan, but the premiums were also several hundred dollars more — over $1,000 more without subsidies — per month.
Even though it was November, the Portuguese night felt like early fall in Sacramento. Farmácias in Portugal are nothing like the CVS or Walgreens we see in America; they are generally small and stocked with vital health items, although it took visits to two different pharmacies to find a small package of tissues, which were kept behind the counter. Pharmacists in Portugal have been given a key role in promoting self-care and overall public health.
Just on a whim, I had brought with me my prescription for Eliquis that also clearly stated a generic was acceptable, even though one was not available in the U.S. Seeing the flashing green cross and clean, well-lit storefront, it seemed worthwhile to take a short walk down the cobblestone street to see if it could be filled and what the cost would be. Two pharmacists were working late, and I was directed to the one who spoke more-than-adequate English. Yes, she said, she could fill the prescription, and walked into the back of the pharmacy.
Less than five minutes later and after showing my passport, I had three months of Eliquis — in the form of Teva’s Apixibano generic — in my hand. The price: about $100 euros, or roughly $110.
That’s just a fraction of what a similar prescription would be in the U.S. and the difference essentially covered the airfare from San Francisco to Lisbon. That’s the kind of savings you used to be able to get by flying to Germany to pick up your Audi and drive it around the country before shipping it back to the U.S.
As a patient, this was a stunning discovery. It also was, simultaneously, a statement about one country’s commitment to accessible health care and the lack of a similar commitment in America. In Portugal, all residents, nationals and foreigners enjoy the full right to health and drugs are often subsidized 70% or more by the government, and the right to health care for all is enshrined in the country's constitution. The contrast might be lost among Americans who only see copays of $10 or $50 in a system in which most people get health insurance through their employers and have little recognition of how drug costs lead to high premiums that put a strain on businesses, including doctor’s practices.
A comparison of Medicare drug plans for a Sacramento ZIP code shows that while copays vary, the total cost for a year of Eliquis is staggering. The combined annual cost of premiums for Medicare Part D plans and copays for Eliquis runs from $1,900 to almost $2,500, with most of that heavily front-loaded. Even stranger, one of the lowest total costs was actually for the Part D plan I’m on, which dropped from $8 per month last year to 40 cents — yes, cents — per month in 2024. That drop was due, at least in part, to the decision to limit access to a new Alzheimer’s drug that had been priced as high as $56,000 per year.
The AMA has recognized that much can be learned from other countries, but the disparity in drug prices is probably not all that high on the radar for individual physicians. The first priority for physicians is providing the best care and that, not the cost to patients, naturally drives their prescription decisions. Eliquis is a state of the art drug that seems to have fewer risks and side effects than some of its lower-cost predecessors, and that’s one reason it is prescribed so often by physicians and so wildly successful for BMS and Pfizer. In addition, because of the myriad and diverse insurance plans covering their patients it’s easy to overlook the potential out-of-pocket costs for patients and there is little incentive to offer alternative prescriptions or guidance on where to fill their prescription for less.
But should physicians make lowering drug prices a higher priority of their advocacy? Oddly enough, most of the doctors — very good doctors, by the way — and pharmacists I’ve told my experiences to almost all seem genuinely shocked and shake their heads, which says some education is needed if it’s an issue that will have significant traction. From a patient perspective, the answer is they absolutely should: an estimated 45 million Americans didn’t fill prescriptions because of the expense back in 2016, and it’s a safe bet that the number has grown since then. That, along with reimbursement rates squeezed by the percentage drugs take of the premium pie, means the care physicians provide to patients is being compromised.
Portugal was just the latest stop on my pharmaceutical adventure. The prospect of spending almost $10 a tablet twice a day had already sent me on a voyage of international pharmacy tourism. The first stop, at least on the internet, was Canada. Where a 90-day supply can be over $500 — and several times that annually for those on a lifetime regimen — at a local U.S. pharmacy depending on your pharmaceutical plan or lack of one, a similar prescription from a certified Canadian pharmacy is only about $350 and can be delivered to your door in a little over a week.
One reason Eliquis is cheaper in Canada is that, unlike the U.S., a biologically similar generic is available. Bristol Meyers Squibb and Pfizer, the two companies that co-developed Eliquis, went on the attack in the U.S. in 2017 with patent lawsuits against several companies that filed to produce generics of the drug, Eliquis was Pfizer’s third-biggest drug in 2022 with over $6.5 billion in revenue, and industry analysts say it could mean as much as a $20 billion drop in revenue once the patent expires in the U.S. Things won’t change here soon: even though the patent was originally set to expire last year, the U.S. Patent and Trademark Office extended the patent until 2026 but it may not be until a year or two after that until generics are available and prices begin to drop.
Eliquis is one of ten drugs that accounts for about $50.5 billion in gross Medicare Part D pharmaceutical costs, or about one-fifth of all expenditures. That likely doesn’t reflect the total cost, however, because the National Institutes of Health estimated over a decade ago that at least one million Americans were getting their prescriptions from online pharmacies in other countries. In 2023, the U.S. Department of Health and Human Services announced that Eliquis would be one of the first drugs targeted for lowering costs under the Inflation Reduction Act under a new authorization to negotiate prices through Medicare. Whatever the new price will be won’t take effect until early 2026.
Buying pharmaceuticals from other countries can have risks, such as scams that provide counterfeit drugs that are ineffective or harmful. U.S. pharmacies are allowed, in partnerships with states, to import pharmaceuticals that are available at a lower cost from distributors and pharmacies, but even the FDA’s first authorization in January for Florida to buy from Canadian wholesalers seems destined for failure. Canadian distributors have shown zero interest in participating and there is little incentive north of the border to ship pharmaceuticals south and possibly create shortages for Canadian citizens. In addition, patent restrictions effectively prevent the importation of any generics of drugs such as Eliquis.
“This whole thing is a jerry-rigged, complicated approach to a problem that’s amenable to a pretty straightforward solution, which is that you empower the government to bargain over the price for drugs,” Nicholas Bagley, a health law expert at the University of Michigan Law School said to the New York Times in a comment about Florida’s plan. “So instead, we’re sort of trying to exploit the machinery that Canada has created and that we were too timid to create.”
Despite attempts through legislation and executive actions, Americans have never been legally authorized to get prescriptions from offshore pharmacies. But it’s a bit of a gray area; even though these sales could technically be stopped, the FDA policy is essentially to look the other way and whistle innocently. The agency’s guidelines give it the discretion to permit the personal importation of pharmaceuticals “when the quantity and purpose are clearly for personal use, and the product does not present an unreasonable risk to the user.” These fuzzy rules — probably along with some perks from pharma reps and the possibility of counterfeit medications, among other malpractice concerns — understandably make many physicians hesitant to recommend ordering internationally to their patients. Knowing what reliable options are available, however, is a service that can be of tremendous help to patients facing large out-of-pocket costs.
Even though Americans technically can’t get their prescriptions filled outside of the country, millions do each year either by crossing a border or ordering online. What drives them is simple: cost. Eliquis is a good example of how costs here, where it is available exclusively as a brand-name drug, at prices that are almost entirely set by its maker, are out of proportion to the rest of the world. The median price for a month’s supply (60 5mg tablets) in the U.S. in 2019 was $440, two and a half times the next most expensive price of $162 found in Switzerland. A similar prescription was $142 in the United Arab Emirates, $102 in Spain, $96 in Germany, $80 in Greece, $65 in South Africa and $61 in Kazakhstan.
There’s little doubt that the median price has gone up over the past four years and that the spread has grown between what Americans pay for Eliquis compared those in other countries in need of an anti-coagulant. Even private insurance plans where the copay is far less than the out-of-pocket cost must reflect those prices in the premiums they charge. That’s why each package that arrives or purchase made at a foreign pharmacy where approved, safe brand-name or biologically equivalent pharmaceuticals are sold seems to be greeted by dose of dismay at the American health care system and the same question: Why can’t we do that here?
That’s a whole another article, but the short answers are the drug companies’ free reign to set what ever price they want in a market for which they know their products can be a life-or-death choice in a distorted form of capitalism; lack of pricing regulation or negotiating power by the government; the absence of subsidies other countries use to promote the health and efficient care of their citizens; and friendly patent protections — even for drugs developed with the help of taxpayer money — that prevent lower-cost generics from entering the market and lowering prices.
I’ve recently discovered another wrinkle that makes it just a bit more difficult for Americans to take advantage of lower international prices. Providing a prescription to a reputable pharmacy in Canada, Portugal or another country on your travel list usually requires that it be written so it can either be scanned or hand-delivered, but many providers now only send prescriptions to the patient’s preferred pharmacy electronically. Despite the obvious security benefits, it raises the question of whether there was also a subtle ulterior motive to discourage pharmaceutical tourism.
At this point, inaction is both helping and harming those seeking to keep their prescription costs manageable, especially seniors on limited incomes who have severe health issues. It’s helping because the FDA isn’t fully standing in the way of keeping international sources open for individual patients, but on the other hand not much is really being done to address the problem for the long term. Except for an initial round of negations that aren’t assured to be successful for drugs that sound like characters in a sci-fi Italian opera — anticoagulants Eliquis and Xarelto, diabetes drugs Farvica, Januvia, Jardinance and Flasp, the cancer drug Imburvica, Enbrel for rheumatoid arthritis and the Crohn’s disease drug Stelara — there seems to be very little movement or appetite among legislators as a whole to address this glaring hole in the American health care system.
Until they do, it will simply give more Americans the incentive to visit the local farmácia while they are traveling or seek online answers, even if they don’t do the due diligence needed to make sure they are dealing with above-board sources. In the meantime, each prescription simply reinforces the widespread belief that despite the best efforts of physicians, the American health care system is failing at delivering what should be its most important mission: providing affordable, efficient and equitable care to those who need it.
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Ken Smith is managing editor of SSV Medicine.
