Introduction

Since 2017, the prescription medication expenditure in the United States has averaged $340 billion per year. It remains as having the highest total drug spending among developed countries as it is driven by both increases in price growth in spending per prescription and medication usage.^1,2 Medicare is a primary source of all healthcare coverage for many Americans. In 2022, 49 million of the 65 million Americans covered by Medicare are enrolled in Part D plans, and the demand in the 65-and-over population is projected to increase by three percent per year over the next five years.³ Additionally, the population of Americans 65 and older is projected to grow to nearly a quarter of the US population by 2060, which will likely increase total Medicare spending.⁴ Therefore, it is imperative that healthcare programs, such as Medicare, prioritize reducing excessive pricing of prescription drugs and reduce medical waste.

The economic burden posed by wasteful healthcare spending in the United States has resulted in increased out-of-pocket expenses for medical services and prescription drugs.^5,6 Therefore, it is essential to develop new possible and affordable methods of obtaining medications. The Mark Cuban Cost Plus Drug Company (MCCPDC) operates on a transparent pricing model, offering generic medications at a fixed markup: the cost of ingredients plus a 15% margin, a $3 pharmacy fee, and $5 shipping. Unlike traditional pricing mechanisms influenced by pharmacy benefit managers and insurers, MCCPDC bypasses intermediaries to reduce consumer costs through direct-to-consumer pricing.^7,8 These market values provide an avenue for potential consumer savings, especially from companies, which do not manufacture their own medications – such as Medicare programs. Several studies have depicted that Medicare would benefit from adapting the model set forth by Mark Cuban. While examining urologic and oncologic drugs, Cortese et al estimated that taxpayers could save over 1 billion dollars by using the MCCPDC program.^9,10 These findings suggest further research is needed in other disciplines to explore reductions in Medicare enrolled patients.

While prior studies, such as those by Cortese et al and Lalani et al, have analyzed potential Medicare savings from the adoption of the Mark Cuban Cost Plus Drug Company (MCCPDC) model for oncology and urologic drugs, our research uniquely focuses on anticonvulsant medications, an area of critical importance due to the increasing prevalence of epilepsy in the United States.^10,11 To our knowledge, no previous study has systematically compared MCCPDC pricing for anticonvulsants to Medicare Part D spending data. This focus allows us to explore cost-saving opportunities specific to a vulnerable patient population, namely those who rely on lifelong treatment for epilepsy, where medication affordability and accessibility are paramount.

Epilepsy prevalence in American adults was almost 3 million in 2021, with mortality rates rising over the past 25 years.^12,13 Meanwhile, Medicare Part D spending on antiseizure medications increased from $1.16 billion in 2012 to $2.68 billion in 2020.¹⁴ This increase highlights the growing financial burden of providing essential medications to patients with epilepsy. The burden is highly prevalent as Tian et al states that adults with epilepsy were more likely to report an inability to afford prescription medicine, skip medication to save money, and delay obtaining refills.¹⁵ Additionally, proposals to weaken Medicare’s protected classes may further burden those needing anticonvulsant medications, leading to seizures, accidents, or death.¹⁶ Epilepsy is a lifelong condition, and limited access to necessary drugs would greatly diminish quality of life. Therefore, epileptic patients could greatly benefit from the advantages of the MCCPDC. To our knowledge, no previous research has been done to compare medication prices to those seen in MCCPDC for anticonvulsants. Due to the financial complications associated with epilepsy, we aim to determine the potential savings for anticonvulsant prescription medications in the MCCPDC compared to the Medicare Part D plans.

To help orient readers, we provide background on the two platforms central to this study. The Mark Cuban Cost Plus Drug Company (MCCPDC) offers generic medications at a fixed markup, plus standardized pharmacy and shipping fees, with pricing fully transparent on its website. Medicare Part D is a federal prescription drug program for Medicare beneficiaries, and its public database includes yearly spending and utilization per drug.

Our approach to identifying, extracting, and comparing prices was informed by Schloegel et al, who evaluated MCCPDC pricing for urologic medications and compared it to multiple sources, including Medicare Part D.¹⁷ Their systematic methods for capturing 30- and 90-count pricing and considering insurance-adjusted costs served as a practical model to structure our methodology and orient the reader on the review process.

Methods

Reproducibility and Study Design

We conducted a cross-sectional review to identify the difference in price of anticonvulsants available on the MCCPDC website compared to the 2021 Medicare Part D spending data. We used this price comparison to determine the potential savings for Medicare based on MCCPDC prices. Our methodology was adapted from Schloegel et al, who analyzed urologic medication prices across multiple pharmacy platforms, including MCCPDC and Medicare Part D.¹⁷ Specifically, we followed their approach of extracting 30-count and 90-count prescription prices and calculating potential savings using volume-adjusted Medicare Part D data. Our study was conducted in accordance with the best practice recommendation according to GRACE (good research for comparative effectiveness) and CHEERS (Consolidation Health Economic Evaluation Reporting Standards).^18,19 We used similar methodology conducted by Cortese et al and Lalani et al.^10,11 To ensure the transparency and reproducibility of our results, we uploaded our methodology and protocol to Open Science Framework (OSF).²⁰ This study does not involve human subjects as determined by the Institutional Review Board.

Inclusion/Exclusion Criteria and Data Extraction

All seizure drugs available on MCCPDC were compared in this study. We compared drug costs for 30-count (30ct) and 90-count (90ct) prescriptions—packages containing 30 or 90 tablets/capsules, respectively—between MCCPDC and Medicare Part D. Our analysis excluded drugs that were not available for comparison in the 2021 Medicare Part D spending data, drugs not in 30 count (30ct) or 90 count (90ct) prices on MCCPDC (1 bottle, suspension, etc), and drugs not in the form of tablets or capsules (ie liquid medications). To estimate the 2021 Medicare Part D spending, we adopted a conservative approach by selecting the most expensive dosage when multiple options were available. The unit drug prices, including pharmacy dispensing/shipping fees, were obtained for both the minimum (30 ct) and maximum (90 ct) quantities from MCCPDC.

Data Analysis

We calculated the potential Medicare savings by determining the difference in standardized 30ct or 90ct prices between Medicare and MCCPDC. This difference was calculated by taking the unit price and multiplying it by the volume-adjusted number of units dispensed to Medicare enrollees in 2021. This difference was represented as delta 30ct and delta 90ct. We used the publicly available Medicare Part D Prescribers by Provider and Drug dataset.²¹ Unit costs were calculated by factoring in the $5 shipping costs to the most expensive 30ct and 90ct prices and dividing by their respective quantities.

We define ‘saving’ as a price lower on MCCPDC compared to Medicare Part D. We define ‘cost’ as a price higher on MCCPDC than Medicare Part D. Further, a more negative percent difference indicates ‘savings’, while a more positive percent difference indicates increased ‘costs’. Therefore, we define ‘highest saving’ as the values that had the most negative percent difference between MCCPDC and Medicare Part D and ‘highest cost’ as the values that had the most positive difference between MCCPDC and Medicare Part D.

Results

Our sample included 16 anti-seizure medications that appeared on both MCCPDC and Medicare. Of these drugs, we excluded valproate sodium because it is a liquid medication rather than a tablet/capsule for a final sample of 15 medications. The overall Medicare spending among these 15 drugs was nearly $1 billion. The 30ct prescriptions found potential savings in 9/15 (60.0%) drugs to be $172 million using MCCPDC. However, the average cost of all 30ct drugs on MCCPDC was 14.85% more expensive than Medicare prices. For the 90ct prescriptions, potential savings were found to be $373 million in 12/15 (80.0%) drugs and $283 million (31.63%) cheaper than Medicare prices. A more detailed breakdown of cost differences can be seen in Table 1.

Table 1 Change in Price

In our analysis, the overall 30ct cost was $134 million for all 15 drugs. The highest potential 30ct saving was $83 million for divalproex sodium (extended release) with a percent difference of −60.14%. The highest cost was $146 million for lamotrigine with a percent difference of +241.63%. These differences can be seen in Figure 1.

Figure 1 Total Cost for 30ct Anticonvulsants in Medicare Compared to MCCPDC.

The overall 90ct savings for all drugs was found to be $283 million. The highest potential saving in 90ct drugs was divalproex sodium (extended release) at $107 million with a percent difference of −77.57%. The highest potential cost was lamotrigine at $87 million and a percent difference of +144.71%. These savings/cost differences and other drugs are visualized in Figure 2.

Figure 2 Total Cost for 90ct Anticonvulsants in Medicare Compared to MCCPDC.

Discussion

Our study found that MCCPDC offered greater cost savings for 90ct prescriptions than for 30ct. Specifically, 80% of 90ct drugs were cheaper than Medicare, with total savings of $373 million and a 31.63% average price reduction. While 60% of 30ct prescriptions showed individual savings, their average cost was 14.85% higher than Medicare, likely due to the fixed $5 shipping fee having a greater impact on smaller quantities. These findings suggest MCCPDC may be most beneficial for chronic conditions requiring higher medication volumes. Similar trends were reported by Schloegel et al (2024), who found MCCPDC often undercut traditional and insurance-based pharmacy models for 90ct urologic medications.¹⁷

Despite an average increase in cost for 30ct prescriptions, the presence of savings in the majority of individual drugs suggests targeted opportunities for cost reduction. Specifically, certain high-cost drugs on MCCPDC inflated the overall average, while others offered substantial discounts. Therefore, the overall potential for Medicare savings lies in selective adoption rather than wholesale substitution. The majority of 90ct seizure medications and overall price difference to be cheaper using MCCPDC demonstrates a potential benefit to buying a larger dose. Further, this can be supported by the fact that epilepsy is typically a lifelong condition²² and, therefore, a larger medication count would be beneficial to long-term treatment. The MCCPDC model has provided a cheaper alternative to obtain essential medications that has long been dominated by pharmaceutical companies. Our findings suggest that, in some cases, MCCPDC could lower patient costs and improve access, particularly for chronic therapies. However, these benefits depend on specific drug pricing and prescription volume, and are not guaranteed across all medications.

Implications of MCCPDC’s Incomplete Formulary and Potential Systemic Effects

The MCCPDC model’s reliance on a ‘Usual & Customary’ (cash price) approach, while beneficial in reducing costs for specific drugs, presents challenges due to its incomplete formulary. Patients requiring medications not offered by MCCPDC may face polypharmacy issues, wherein they must source medications from multiple pharmacies. This fragmentation can increase the likelihood of medication errors, reduce adherence, and complicate the coordination of care. Furthermore, additional shipping costs for medications sourced from MCCPDC could offset potential savings, particularly for patients managing multiple chronic conditions.

The systemic impact of MCCPDC’s model also warrants consideration. Pharmacy benefit managers (PBMs), which negotiate drug prices and reimbursement rates, may adjust contracts to compensate for lost prescription volume. This could manifest as increased fees for remaining prescriptions or stricter formulary management, potentially shifting costs back to patients and healthcare payers. Future research should explore these systemic adjustments and propose solutions to mitigate unintended consequences, such as collaborative models that integrate MCCPDC’s pricing with existing pharmacy networks.

Addressing Potential Harms of Polypharmacy

The MCCPDC model introduces potential logistical challenges for patients. Dividing prescriptions between MCCPDC’s mail-order service and local pharmacies may result in treatment delays, reduced continuity of care, and complications in maintaining accurate medication records. Additionally, patients who rely on face-to-face interactions with pharmacists for medication counseling may lose access to this critical resource for MCCPDC-sourced prescriptions. To minimize these harms, future iterations of the MCCPDC model could explore partnerships with local pharmacies to streamline access while maintaining cost savings.

Building on Existing Research

This study builds on existing research by extending the analysis of MCCPDC’s potential benefits to the domain of anticonvulsants, a category previously unexamined. Unlike oncology or urologic drugs, which may have episodic usage patterns, anticonvulsants are often required continuously for the lifetime of the patient. This distinction highlights the unique savings potential and patient impact in the context of chronic disease management. Additionally, our analysis offers a deeper understanding of how MCCPDC’s pricing model could address specific affordability barriers faced by Medicare beneficiaries with epilepsy.

Conclusion

In addition to the demonstrated cost savings, adopting MCCPDC’s pricing model requires careful consideration of systemic and logistical challenges. Policymakers and healthcare providers should prioritize integrated care solutions to ensure patients can access affordable medications without compromising continuity of care. Collaborative initiatives between MCCPDC, PBMs, and traditional pharmacies may enhance the scalability and sustainability of this model. Finally, patient education is critical to ensuring that individuals can navigate polypharmacy challenges effectively and maximize the benefits of MCCPDC’s pricing.