Utilization of an Online Cash-Pay Pharmacy for Topical 5-Fluorouracil Prescriptions in Older Patients

May 2020 | Volume 19 | Issue 5 | Original Article | 539 | Copyright © May 2020

Published online April 2, 2020

Jessica E. Payne BS,a Rima I. Ghamrawi,a BS, I-Chun J. Lin MD, a,e Steven R. Feldman MD PhDa,b,c,d

aCenter for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC bDepartment of Pathology, Wake Forest School of Medicine, Winston-Salem, NC cDepartment of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC dDepartment of Dermatology, University of Southern Denmark, Odense, Denmark eDepartment of Epidemiology, Fielding School of Public Health, University of California Los Angeles, CA

Background: High cost of prescription medications presents a challenging issue for older patients with multimorbidities. Topical 5-fluorouracil (5-FU) is an effective treatment for actinic keratoses (AK), a highly prevalent condition among elderly populations, but it is often associated with unpredictable retail prices and high out-of-pocket costs. One online pharmacy offers branded prescription medications at fixed, low prices, but it may be less accessible to older patients for numerous reasons.

To determine if the number of patients receiving topical 5-FU from an online pharmacy is proportionate to the national data on expected payment types for patients prescribed topical 5-FU for AK.

We conducted a cross-sectional study using weighted pooled data from the National Ambulatory Medical Care Survey (NAMCS) on topical 5-FU prescriptions for AK from 2007-2016. Data regarding online pharmacy use were provided by Dermatology.com for the year 2019.

Among patients with AK prescribed topical 5-FU, the most prevalent payment source was Medicare (54%) followed by private insurance (40%). On the online pharmacy, the majority of patients had commercial insurance (71%) followed by Medicaid (12%). Limitations: Data from Dermatology.com are limited.

Lower-cost medications from the online pharmacy site may improve adherence and outcomes in older adults and decrease total cost associated with AK treatment. However, the online pharmacy is underutilized by this population.

J Drugs Dermatol. 2020;19(4): doi:10.36849/JDD.2020.4690


The high cost of prescription medications continues to be a challenge for patients and prescribers in dermatology. Strategies to control drug expenditures and to decrease healthcare spending in the U.S. have contributed to higher deductibles and copayments, as well as more restrictive third-party formulary listings.1 To add to the burden, the costs of generic medications commonly prescribed in dermatology have risen dramatically. From 2005 to 2016, the average wholesale price of topical generic and branded medications increased by 273% and 379%, respectively.2 Rising drug costs present a particularly challenging issue for older adults, a population at increased risk for cost-related medication nonadherence in association with multiple comorbidities, lower socioeconomic status, and functional limitations.3

In March 2019, Ortho Dermatologics launched Dermatology.com, a cash-pay prescription program in dermatology with the stated mission of providing patients with direct access to branded dermatology medicines at lower, predictable prices. The program does not accept any form of insurance, thus eliminating co-pays, unpredictable pricing, and prior-authorizations from the process of filling prescriptions. Dermatology.com providesproducts that treat a number of dermatologic conditions at prices ranging from $50 to $115.4 Prescriptions can be delivered directly to patients using Medvantx, an online pharmacy associated with Dermatology.com (https://www.medvantxrx.com/), or they can be picked up at a local Walgreens. One of the products available on Dermatology.com is topical 5-fluorouracil (5-FU) 5% cream at the fixed cost of $85 for 40g. Topical 5-FU is an effective treatment for actinic keratoses (AK), a highly prevalent condition among older, fair-skinned individuals with Medicare.5 However, topical 5-FU has been associated with high retail prices and out-of-pocket costs.6

A recent study reported a 1,240% increase in the cost of branded topical antineoplastic products from 2009 to 2015.8 An online, fixed price pharmacy site could potentially help alleviate the concern of rising drug prices for older adults with Medicare by providing direct access to branded dermatology products with reasonable and predictable prices. However, the online platform may be less accessible to older adults, a population with lower access to and usage of the internet.9 The purpose of this study was to determine if older Medicare patients utilize the online pharmacy in proportion to national data on the amount of similarly aged Medicare patients prescribed topical 5-FU for AK.