unPAUSED with Dr. Mary Claire Haver - Estrogen Patch Shortage: Who Profits From Your Prescriptions with Mark Cuban

Episode Date: October 13, 2026

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with entrepreneur Mark Cuban, cofounder of the Mark Cuban Cost Plus Drug Company, to unpack the estrogen patch shortage and why so many women in perimenopause and menopause struggle to find and afford hormone therapy. Holding up her own patch, Dr. Haver asks the question her patients keep asking: why is this so hard to get? Mark explains why the shortage hit so hard — patches require specialized manufacturing that pills don't, demand surged after the black box warning was removed, and supply couldn't keep up — plus how Cost Plus Drugs has worked to buy every patch manufacturers can produce, and who gets served first when a generic drug runs short.Then they take apart how drug prices are really set: how pharmacy benefit managers (PBMs) decide what your insurance covers, how rebates drive list prices higher, and why a handful of conglomerates now own the insurer, the pharmacy, the PBM, and the physician practice all at once. They compare what a generic estradiol patch costs to make against what many women pay at retail, cover Dr. Haver's case for vaginal estrogen as one of the most affordable treatments in menopause care, why there's still no FDA-approved testosterone for women, how untreated symptoms push women out of the workforce, and the playbook for lowering your prescription costs — from 90-day supplies to comparing cash prices with your copay.Guest links:Mark Cuban Companies https://markcubancompanies.com/Cost Plus Drug Company https://www.costplusdrugs.com/Mark Cuban (Instagram) https://www.instagram.com/mcuban/Mark Cuban (X) https://x.com/mcubanBooks:"The New Perimenopause," by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book"The New Menopause," by Dr. Mary Claire Haver https://www.amazon.com/dp/B0CKBZ4K1ZArticles:Menopausal Hormone Therapy Use Among Postmenopausal Women (JAMA) https://jamanetwork.com/journals/jama-health-forum/fullarticle/2823976

It's a scam from top to bottom. Nobody looks at the economics of healthcare and says it's working well. So in the past two years, estrogen patch prescriptions have nearly tripled. Oh, my God, at least 10x. It was hundreds of dollars for a simple tube, and you were selling it for 1345 or something. It shows you our markups only 15%. It's on short supply because money? Yes.

If it's harder to get, you can price it more. This can't be legal. These middlemen, too big to care. Don't give a shit. My next dollar is not going to change my life. but my next dollar might save somebody's life. Less than 9% of NIH grant money went to women's health over the last decade. Why do you think that is?

It's run by men. What was truly missing was in his trust. I'll give you the craziest example, and that's how I found out about the Everalimas. The views and opinions expressed on unpaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Every time I post about what medication cost on social media, my comment section explodes.

One woman pays $14 for her estrogen patch. The next one pays 90. Same drug, same dose, same country. And underneath almost all of it, the same question. Asked 100 different ways. Why isn't the cost consistent? Two women can be handed the same prescription on the same day and pay wildly different prices, and neither of them can understand why. That is not an accident. It's how the system was built,

and lately, a lot of you can't get your estrogen patch at all at any price. Here's why it's so confusing. Between your doctor and your pharmacy, sit a handful of middlemen between drug companies and your health insurance. There are the ones negotiating medicine prices and deciding which drugs your insurance will cover. My guest, Mark Cuban, is an entrepreneur and investor, many of you may know as one of the sharks from Shark Tank. He has built and run many different types of companies, including the Mark Cuban Cost Plus Drug Company. He co-founded the company in January of 2022 and spent four years inside the machinery of how drugs get priced, bought, and distributed in this country. With the Mark Cuban Cost Plus Drug Company, he did the thing this industry treats as radical.

He published the price of each medication with transparent pricing and a limited markup. It's all right there on his website. And today, we're going to talk about how this has fundamentally changed the pricing of medications in the United States. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner and adjunct professor at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. This podcast is sponsored by Middy Health. the first virtual clinic created for women by women for the treatment of menopause.

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first order. Your menopause specialized doctor will help you build a skincare plan for your needs. Plus, you get $0.00, unlimited messaging with your doctor. Head to M-Y-A-L-L-O-Y.com and use code M-C-H-20 to get 20% off your first order. This code is valid on products only. These are compounded products not subject to FDA approval. Mark Cuban, welcome to Unpaused. Thanks for having me.

So I'm excited to have you on the show, mostly because, because you are a problem solver, and we have big problems in women's health and supply chain for our estrogen patch, which I brought mine in today. What are you doing differently with the cost plus drugs versus me going to CVS or Walgreens? So it's costplusdrugs.com is our site, where what makes us different initially is when you go, we show you our actual costs. When you put in a stradio, whatever it may be, and it comes up, we'll show you what our cost is, what our markup is, and that typically means we're going to sell it for less than everybody else. So that's our initial goal to make sure it's affordable, because it doesn't matter if it's

available if you can't afford it. Right. And so affordability is a key for us. Transparency is a key for us. But like everybody else, we're very aware that there's a shortage of a lot of HRT therapies. And so what we've done is rather than having one vendor or sometimes we'll have two, but typically one vendor, we've gone out and sourced. every source that we possibly can find. We've gone to the two major manufacturers and said, look, we will take every unit of inventory that you're able to give us. And it's crazy because we still can't keep up. We thought, okay, we have enough inventory or are we going to be able to sell it all? And it just flipped completely around. And because of that, the two primary vendors

that we use have completely different pricing. And so we made the conscious decision to say, even if we run out of inventory of the less expensive one, we're going to explain to people that, look, we want to make sure that there's inventory available. Our most expensive version is still less expensive than most retail pharmacies. So we'll make that available to you. And you'll have the choice of ordering, you know,

the more expensive one, we're waiting for the less expensive one. And because we wanted the availability because both prices are better than typical. And that's worked for us so far. We still run out every now and then, but literally we are trying to buy up everything we can. If we were able to manufacture it, we would. But because it's the patches, it's a lot more difficult.

We're not geared to do that. And we've gone to some of the manufacturers, and we've literally asked if we can buy out their entire volumes. All right. Hormonal medication. So in the past two years, estrogen patch prescriptions have nearly tripled. So this whole menopause gold rush. And our volumes are far more than you. scene. Oh my God, at least 10x. Yeah. I mean, it went, I don't know when the trigger point was when

the rules changed, but all of a sudden I was like, oh my God, we're out of stock. Black Box morning was one watershed moment, you know, that people were less scared to go get their prescription filled, and doctors are getting more comfortable prescribing it, yeah. Prescribing it. But I think it's 44% of all estrogen scripts are now the patch specifically. Why do we have specifically a patch shortage versus oral estrogen shortage? Oral is really easy to make. The patches require specialty in manufacturing. If I could just gen up a manufacturing plant that could do the patches. Yeah, because it would take five years. I don't know five years, but it's going to take a period of time. So demand for the patches at least tripled in two years, but the supply didn't.

Right. Did no one see this coming or? Okay. No. If they didn't care. Yeah, it's not that they didn't care, right? I don't think people really, you know, once a drug goes generic, just the way it's dealt with. The economics.

Yeah, the economics are completely different. And the manufacturers who had been making it, you know, if the numbers are the same for years, you don't anticipate that all of a sudden it's going to change. And then it did. And now they're responding and they're adding capacity. But they were forced to, I think. Well, they could have raised the prices, but they chose to add capacity, and we really tried to push them to that. There was a letter-writing campaign to the FDA when women couldn't find their patches.

So first, on the website, on the FDA website, I would say there's no patch shortage. Everything's fine. Everything's fine. But like millions of women are on social media screaming that they can't get their patches. And then finally, just in the last week, the FDA wording changed on the website that they're working. working with six manufacturers to try to, you know, encourage them to, what happens when we run out of stuff? Like, how does the FDA get involved? I think they can approve manufacturing plants or expansions more quickly.

Okay. And that's a help. But it really just is how quick is the acceleration of demand. Okay. Because it's one thing to say we're going to make more. But if you make, you know, more for twice the demand thinking you're capturing everything, but, you know, the number, the acceleration rate because women are getting more comfortable. and doctors are, is five times that you're going to be behind no matter what.

And I think that's what we really ran into. It wasn't a lack of interest. It was more, oh, my God, at least that's what it was for us. It was, okay, stradial, okay, it's going up the sales charts, right? Now it's a big hit, and what can we get? What do you mean, that's all we can get, you know? And, okay, we'll add manufacturers, and we'll keep on just adding manufacturers wherever we can. but it was just the demand just outstrip the supply far more than they could add supply.

The demand isn't going to go down for menopause hormone therapy. I only predict it getting increasing. Population age. We had about 40% of women who were eligible on hormone therapy. We're still less than 10% right now. Yeah. But literally we've tried to buy manufacturers. I've tried to buy a manufacturer.

I get it, right? Yeah. I see it in my family. My husband jokes, we should buy an estrogen patch factory. And we're kidding. We have no real plans to do that. No, but I would if I could. And to build one is just not a simple task.

But we discussed it. And, you know, it wasn't something we could do, but we're looking to try to pre-buy as much of people's inventories as we can. Would it be easier to make the gels or the sprays? Yes. I think it would be, but they're still under patent. Like, why don't we have a generic for those yet? Because of the patent. Okay.

Okay. I don't know the exact dates they come out of patent, but you can look those up really. Yeah. All right. So I want to walk our listeners through this. I'm on your website right now. Okay. And this is the dottie estradiol twice weekly.

That's basically this, generic. You know, this is the generic patch I have it in my hand. And on video, we're going to fly in actual images from the website. So your drug price with us, 398. That's just slightly higher than I think that's the more expensive price, but it's not really that much more. I think it's like 25 before. So, and you have in stock the 0.05 and the 0.1, which are the two most commonly prescribed

one, so yay. So you save $146.69 in your medication, and here's why. I love how you say this. So retail price at other pharmacies. Now, is this the retail price for the brand name? No. This is the generic. It's the generic, but there's a standardized price called NADAC, and that's what we use to determine.

Because if you just walk into a pharmacy as a cash pay, in most retail pharmacies, that's what they'll charge you. Without like a good RX coupon or something. Even with sometimes. Okay. So manufacturing price, this is your price that you paid the manufacturer was $29.72. Your 15% markup, which is you markup across the board, was $4.46. cents. Pharmacy labor, so to go get that filled and, you know, $5.00. And then the standard shipping, $5.25. That's where we get our $39.18 from. So this person, me, saved $146.69.

Had I not just gone to whatever pharmacy walked in and paid the price, we got my insurance. Where is that $146 going? It's not going to us. I mean, that's when I mentioned earlier. And I throw my credit card down. Where's that Delta going? Who's, He's profiting. Okay, so it's like some pharmacies, so you're saying if I bought it for 146, where's that money? Oh, into the pocket of the pharmacy. So take me back to 2022 when you started the company. Why?

Why did you do this? Why? Because nobody looks at the economics of health care and says it's working well. And specifically for pharmacy, we've all heard of stories of somebody walking into a pharmacy, waiting in line, getting to the counter, and realizing they don't have enough money or a cost more than they expect, and it's horrific, it's tragic. And that was the motivation, that there are drugs that nobody knew the price to. That to this day, unless you're going to cost plus drugs or maybe, you know, good R.X in some cases, you have no idea what a medication costs.

And if you don't have insurance or if you're high deductible, that can create all kinds of economic problems for you and obviously health problems if you can't afford it. So we wanted to be completely transparent because what was truly missing, was and is trust. Yeah. And I look at our primary product at cost plus drugs.com as being trust. And really, to me, it's a formula where trust equals transparency divided by self-interest. And we're the only pharmacy anywhere in the world where you can go to our site and it shows

you what our actual cost is. That's about as transparent as you can get. And it shows you our markups only 15%, which is about as little self-interest as somebody can afford to do and still stay in business. And so because of that, we really focused on trust. We launched January 19th of 2022 with 110 drugs. Now we're to thousands of them. So let's start with the basics for our listeners.

How does the current prescription drug price model work? Like, take what you're doing out of it. Take me back to 2021. Right, typically. Yeah. So typically people have insurance of one form or another. You may have Medicaid, you may have Medicare advantage, you may have Medicare advantage, You may have Medicare, you know, with Part D, then you may have it from your employer.

And so typically you have a plan that you're part of and you know for the given medications that you take what your cost out of pocket is going to be. Typically, not always. So if it's, you know, an inexpensive generic, it might be $5 or $10, whatever. If it's what they call a specialty generic, which is still just a pill, right? But they use it as an excuse to increase the price. you might have a co-insurance, which might cost you $25.50, or if it's a cancer drug or, you know, Averillemus or something might be more than $100 that you're paying out of pocket. And then either the taxpayers or your employer covers whatever the balance may be. That's typically how it works for most

people then and today. Talk to me about tears, you know, as a health care consumer myself, besides being the person writing the prescriptions, I can remember, like trying to help patients would bring in paperwork and, like, sitting there with them trying to figure out what they're out of pocket would be. And, like, I have 15 minutes, maybe with a patient, 10, you know, if it's not a well-woman exam. And, you know, for me to sit there and help them go through the paperwork, to figure out the pricing, to help them, and then source the pharmacy where they're going to get the best deal was, we just don't have time. Yeah, I mean, it's not cost-effective for anybody, and it's maddeny because you want to spend more time with patients,

but what good was your time if they can't get access to the... Right. And so typically that's all part of the plan that they chose, right? Because, you know, there's open enrollment and your employer, whoever, and you go through that whole process. And, you know, to their credit, for the most part, there's apps where you can go and look and look up the medication, and it'll tell you at the patient side, not on the doctor's side.

Right? Real-time pharmacy benefits offered through and, you know, through Epic or whoever is hard to come by right now. And they're actually trying to improve that so that doctors can have more say in what's going on. But really, it comes down to people just thinking it's going to be done the way it's always been done. You know, I chose this plan. This is what I thought would happen. And unfortunately, sometimes they change the plans and the rules of the plans, you know, midstream. But that's typically the way it works. How did you spread the word about this? I found about it on social media. I saw a clip of you talking about something, and then I got curious, went to the website, and I couldn't believe, and I think you had just gotten it on formulary how cheap vaginal estrogen was. And this was right when the GSM guideline, that general urinary syndrome of menopause guidelines were coming out and we were preaching from the rooftops, but patients couldn't afford it. It was hundreds of dollars for a simple tube. you were selling it for 1345 or something, and I just couldn't believe it. Yeah, and that's because we're cost plus.

Literally, we go out there and we find quality manufacturers, and there's some things we manufacture ourselves, but they're more injectables than tubes, creams, or pills. But we go out there and find a quality manufacturer, and then we negotiate. And whatever price we're able to get, we show it and mark it up just 15%. But the better news is, as our volumes go up, and our volumes have really. skyrocket lately, our cost goes down. And that means the cost to the patient goes down as well. And in terms of spreading the word, right, initially it was just my big mouth, right? I have a platform and I get out there and I talk about it, social media, TV shows, whatever it may be.

But we don't spend any money on marketing. We made the conscious choice that we'd rather be able to sell the medications for less because you never know when that Litch, that threshold is, right? Where above this amount they can't afford it. So rather, rather than, you'd rather than, you know, than spending money on marketing and advertising, like a lot of the people in the company wanted to do. I was like, no, you don't understand. When somebody, you know, a cancer drug like a matnip, right, if somebody was paying $900 or looking at paying $900, and our price was $34, they're going to be happy, eh? They're going to tell their doctor.

They're going to tell their friends. They're going to go on the Facebook groups or social media groups. And everybody else who has a similar condition, they're going to say, hey, go check out cost plus drugs. So we went from launching in January 22 to now having millions of people we've helped. So I found a quote where you said the prescription drug industry is the easiest industry you've ever disrupted. Why is that? Because it's really, really simple, right? What's the price? How much does it cost? You know, what's the price? Who pays for it? And if that person can't pay for it, who helps them? Okay. That's it. And we made it clear of what the price is. And we

deal with cash. We deal with some insurance companies through some PBMs, but mostly we just try to make it so as simple as possible. You just go to cost plus drugs.com, you sign up, you find the med, you put in your credit card, you tell your doctor where to send it, and that's it. I've done it online and showed people how to do it. I appreciate that, thank you. And so, especially for the vaginal estrogen. So let's go back talking a little bit more about disparities in drug pricing. I'm on social media a lot. I do a lot of education around menopause. And a few months ago, we were talking about how long did it take you to get your prescription for hormone therapy? And then what was prescribed to you and what did you pay? And there were thousands of comments. And women really shocked by the differences and what she were paying.

So one woman was paying, you know, $25 for her box. Her is happy to be covered by, that was her co-pay. Right. Another woman, it was well over $100. And so why is that? that. So the co-pay is obvious, right? She's paying her insurance premiums and, and even then, your co-bate might still be more expensive than a cash out-of-pocket price. But at the same time, if you walk into a retail pharmacy, they're trying to make as much money as possible. You know, especially if it's part of a big conglomerate, you know, a lot of these big, huge healthcare conglomerates are too big to kick. Welcome back to another midi-paws. I'm Dr. Mary Claire Haver, host of Unpaused. Let's talk about a menopause.

that affects millions of women, but still doesn't get nearly enough attention. Genital urinary syndrome of menopause, also known as GSM. Now, that may sound like a complicated medical term, but GSM refers to a group of symptoms that can affect the vaginal and urinary systems during and after menopause. And the reality is, it's incredibly common. Symptoms can include vaginal dryness, irritation, burning, painful sex, urinary urgency, frequent urinary tract infections, or feeling like you constantly need to use the bathroom. And unlike hot flashes, which often improve over time, GSM symptoms can actually worsen if left untreated. One of the reasons you may not have heard about GSM is because not enough women, and sadly, some doctors know about it.

This lack of awareness can be due to women feeling embarrassed or just not reporting their symptoms. It is important to remember that vaginal dryness is not a little annoyance or something to dismiss. GSM can significantly affect physical comfort, intimate relationships, self-confidence, and overall quality of life. You do not have to suffer in silence. The reason GSM occurs is simple. estrogen plays a critical role in maintaining the health of vaginal and urinary tissues. As estrogen declines during menopause, these tissues can become thinner, drier, and less elastic, leading to symptoms that affect both intimacy and everyday comfort.

Unfortunately, many women assume these changes are just a normal part of aging that they must accept. That isn't true. Effective treatments are available. and the first step is talking to a health care provider who understands menopause care. That's where Midi Health can help. Midi specializes in caring for women during midlife and menopause, including conditions like GSM that are often overlooked or under-treated. Their clinicians help women understand what's happening in their bodies,

discuss treatment options, and develop personalized care plans. Depending on a woman's symptoms and medical history, they may include vaginal estrogen therapy, non-hormonal treatments, moisturizers, lubricants, are other evidence-based approaches designed to improve comfort and quality of life. Just as importantly, Mitty provides a supportive environment where conversations about your symptoms are taken seriously, not dismiss or minimized. The good news is that relief is possible and women don't have to just tolerate these symptoms. go to join midi.com, join M-I-D-I-D-com, and connect with one of their clinicians today.

This podcast is sponsored by Midi Health. You've heard me talk about my menopause toolkit. It consists of nutrition, exercise, hormone therapy, and other medications, stress reduction, sleep quality, and community connection. When you put those pieces together, they don't just ease symptoms. They support your long-term health. That's why I recommend Midi Health. They put your toolkit to work for you.

Midi is a virtual clinic built by leaders in women's health with clinicians who understand the science of female aging and who take the time to understand you. Through one-on-one visits, they listen to your symptoms, your goals, and your concerns, then create a personalized care plan tailored specifically to you. And best of all, Midi is covered by most major insurance plans, making expert high-quality care accessible and affordable for every woman, all of which is why

Midi should be part of every woman's menopause toolkit. Book your virtual visit today at join midi.com. That's join, M-I-D-I-D-com. Insurance coverage varies. Check with your plan for coverage. Let's talk about the conglomerate. Because I saw someone testifying in Congress and they had a, you know, a board popped up. It was, I didn't realize, walk me through a CVS, you know, and all the touch points they have in the health care system. The largest of them has more than 3,000 subsidiaries. They do more than $160 billion a year of intercompany transfers, meaning they work with those 3,000 subsidiaries in every way they can. What's in the subsidiaries?

It might be like for CVS, they own Aetna, the insurance company. You know, it might be the CVS pharmacies. It might be Caremark, which is their pharmacy benefit manager, that works with your employer. It might be, I forget the name of their third-party administrator who works on the medical side and makes the drugs that are infused at a hospital or a clinic more expensive. And so they always default to paying their own subsidiaries more, particularly in a world of the ACA where there's this thing called medical loss ratio, where they have to spend at least 85% of their premiums on health care. Well, if you pay a subsidiary doctor, clinic, pharmacy, more, you reach that threshold,

the 85% threshold much more quickly, and on the alternate side, you get to keep that margin in your subsidiary company. So it's left pocket, right pocket. And then at the pharmacy level, they charge to market, whatever they can get away with. I mean, that's normal business. I'm not mad at them, but, you know, again, that's the difference with cost plus drugs.com, because it's the same price for everybody, no matter what city, what state, what time a day, it doesn't matter. It's the same price. You mentioned the PBM, pharmacy benefit manager. What is that? And that was not a term I'd heard of until probably about a year ago. You start popping up on my fees, talking about this. Raising hell.

Explain to our listeners. If I can, right? Who these people are and who they work for? What's a pharmacy benefit manager? It's just what implies. When your employer, if you get your insurance through your employment, or if you get your insurance through the ACA, or if you get Medicare and traditional Medicare and you buy Part D supplemental insurance, the company that manages the pharmacy benefit is called a pharmacy benefit manager. And their job originally was to just process claims. You know, hey, you know, I need my

strategy all. I'm going to, you know, I've got a prescription. When I show up at the drugstore, they have my prescription, and somebody needs to process that to make sure everybody gets paid. Okay. That's what it was originally meant to do. Okay. Then because in doing that, they were able to build up a formula, you know, the list of drugs that's available to you in your insurance plan, because they were able to build up tens of millions of lives each, they were put in a dominant position where they basically controlled how much volume any manufacturer would get. So if you're on the formulary to the exclusion of your competition,

you were in a great position. Well, the pharmacy benefits managers realize that they could charge the manufacturers for access to that formulary. And that's where you hear these discussions of rebates and everything going on. Now, they would tell you they offer all these other clinical services and everything. I'm not a big fan of that. I'd rather get my clinical services from doctors rather than insurance conglomerates.

But that's what they do. They process claims. They go out, negotiate pricing, and they make determinations of how much you're going to pay as a plan holder. Wow. Does the way that PBMs pay for generic? Does that lead to shortages? It's not so much how they pay for short, how they pay for generics. It's more how affiliated companies of theirs structure their purchasing.

So CVS is a partner with a company called Red Oak. And they go out and together they purchase a lot of generics, probably purchase about lower costs than we do at cost plus drugs. but they retain a lot of that margin. And then because they have to set up a network of pharmacies who want access to all the lives they cover, the plant holders they cover, they tell the pharmacies, we're only going to reimburse you X amount of money for your generic prescriptions that you fill. And by definition, that's going to make them more expensive in certain circumstances. women in menopause are, you know, experiencing besides the shortage, and we'll go back to that in a second. But it's, you know, that's mostly our listeners are women in menopause. But I think it happens across the board where suddenly you're, everything's covered, you're doing great, you've got your meds, and then boom, it's a new year.

Oh, yeah, yeah. And things change. And things change. You can't get it. You can't find it. I know my kids' ADHD Mets was a cap scramble to try to find their medications. Because things are coming off and on formulas. Is that even legal?

It's legal, unfortunately, because what happens is the insurance company that designs the plan and works with or is owned by the pharmacy benefit manager says, wow, things changed in HRT. We're getting a lot more patients that are expecting us to use the, um, premium money that they paid us or that their employer paid us, well, we're spending a lot more and it's so popular, we can charge them more. And again, they're too big to care. Their mission is to make money. When you, you know, they're public companies and when you listen to them talking to Wall Street, you don't ever hear them say, well, our volumes are going up so our price is going to go down to patients. You hear them say, business is great. We have the opportunity to raise

prices. So we're going to do that because we're going to make more money. That's our fiduciary responsibility to their shareholders. But at the same time, the laws are changing so that the PBMs that they own are now being defined as fiduciaries to the employer that they're hired by. And the employer has a fiduciary responsibility to the health and wellness of their employees or their members, employees and their families. And so while these prices have gone up, There's an opportunity for employers, in particular self-insured employers, to respond to this and take their fiduciary responsibility and say no to the PBMs. And that's where I spend a big part of my time is trying to educate CEOs that it's your money.

You did hire this conglomerate to manage all the claims and set the pricing, but at the end of the day, you want the women in your company or the wives or the daughters or the mothers to be as healthy as possible. I mean, that's why you have insurance in the first place. And so a lot of these rules are evolving now and changing right now, and the employers lag behind. Cost plus drugs pricing where Canadians have to buy out of pocket. Most drugs, if it's made available in a hospital in Canada, you don't have to pay out of pocket. If it's not prescribed out of a hospital and the rules are changing, you do have to pay out of pocket. And so we're cheaper than Canadian drugs.

In Germany, there's some of the same things, other countries. So costless drugs, we have people from all around the world trying to buy from us. we can't sell to them. So on the generic side, which is 92% of the prescriptions, the U.S. is cheaper. And I'm proud to say that cost plus has played a big role in that. On the brand side, we're a lot more expensive. On the specialty drugs, on the cell and gene therapy, we're a lot more expensive. Part of that, I would say, and I'm guessing, 70 to 80% of that, is middlemen increasing the price. If you took out the middlemen of that, the pricing structures would change and prices would go down.

Why? Walk me through that. So if you want the inside baseball? Yeah. Okay. So when a brand medication... So say we get a female testosterone approved. Well, pretend. And it's a brand, right?

It's going to be a brand to start. So let's just say it's a $600 testosterone. I don't know what a good price is. I don't know. I'm trying to use... Just pretend it's $600. This is meant to use easy math. Yeah.

And so it's $600 list price. The manufacturer probably has to pay rebates to the pharmacy benefit managers in order to be on their formula. Okay. Otherwise, they're going to say... For the privilege of like having it on the formulary. Right.

So they could sell it. Literally I had a conversation yesterday with a company that sells combogesis, which is a non-opioid pain medication. Yeah. And, you know, they told me that the PBMs that they talked to and all of them basically, all the big ones, the big three,

told them that unless they raised the price, and I forget what their exact price is, but it's under $200. But unless they raised it to $700, with most of that being rebate, not only would they not put them on the formulary, but they will block them otherwise. That's the way this industry works.

And so if you have a testosterone that's supposed to be $600, again, pulling numbers out of the air, what ends up happening now is the manufacturer, there's three big wholesalers too. There's three big pharmacy benefit managers and three big distributors that, in case of the wholesalers,

control 95% of the transactions in pharmacy. You would think they'd be big enough as multi-hundred billion-dollar companies each to go and negotiate a great price. But what ends up happening for brand medications is they'll say, the brand will say to them, okay, we'll give you 5% off. Okay, that's kind of weird. But, okay, so now it's $570 to the distributor. How can they sell to pharmacies?

they can't sell for less than $570, right? Otherwise, they'd be losing money. So now, anybody who walks into a pharmacy for that testosterone is going to pay at least $570.70. And if you don't have insurance or you have a high deductible or you're in your deductible phase, you're probably paying $570 to $600. Now, here comes the crazy part. The manufacturer of that brand testosterone isn't making $570. They are only making $300 to use easy.

money or easy numbers. Why is there a discrepancy between the 570 and the 300? Because they have to take that delta and pay it to the pharmacy benefit managers in order to get placed on those formularies and not excluded. So that's the middleman. You're talking to that. That's the middleman, right? So if we were in a good system, what would end up happening is that brand manufacturer, the testosterone, would say, look, in the old system, I would make $300. I'm going to sell it to this distributor for $310. And the distributor was previously making $30, so they're going to sell it to the pharmacies for $340. They're going to make more.

But now the pharmacies are only paying $3.40 instead of $570, so they can sell to every patient for $230 less. And that is the delta you see between what happens here in the United States versus what happens in the rest of the world. And it's another reason why the prices of brand medications are so high. And the crazier part is when I talk to the CEOs of these brand companies, and I say, why do you do this? You have all these patients who can't afford it for the reasons we mentioned, can't adhere to it if they were able to afford it once, right? Right.

Why are you not doing it this other way that is the more efficient and better for everybody way? And they say to me, they're like, Mark, we literally get threatened by the pharmacy benefit managers who are part of these big conglomerates. that if we don't play by these rules, they will remove not just this drug from that formulary, but all of our portfolio. All right. When a generic goes short, who gets served first? So whoever's hustling on the back end, like if CBS or Walgreens or Mark Cuban or... When a generic goes on short supply, it really depends who the manufacturer is and who they have relationships with.

Okay. And... How did you... How were you... You have patches in supply. Because we're telling our manufacturers more, more, more, more, more, more, we need as much as you can make, and we'll pay you a little bit more. And so that's why you saw we had one really low price, and then we basically sold all they can make. So we went to a manufacturer who charged us more.

But we just felt, I made a decision. I just felt, though, you know, when we got the low-cost patches in, then people, they would be available to people. but I wanted to have a supply even if it was more expensive. Okay. Yeah. Okay. So I want to talk to you about estrogen vaginal cream. Okay.

This was the cheapest I'd ever seen it. I didn't, I had patients we were prescribing it left and right in my clinic. And they were coming back and it was hundreds of dollars. You know, and these poor women were having to choose between X and Y. X and Y, but they had to have this medication or they were having recurrent UTIs, dryness, all the pain, everything. And so I don't know if you know Rachel Rubin or, okay. Dr. Rubin was one of the very first people that reached out to us about this. Yeah, so I find out.

She said you have saved millions of women by being really the first person to have affordable vaginal estrogen. And I owe it to her because she's the one who educated me on it. So she wanted me to make sure I told you. I appreciate you. So your drug price, so the drug price is $13.21. If every single postmedopausal patient, like over 65, use vaginal estrogen regularly, we could save Medicare billions in eurosepsis and hospitalizations and recurrent UTIs. It is the number one preventative treatment for recurrent UTIs, which then can lead to sepsis in death.

And so so much of this could be prevented. And you were the first person to make this affordable for our patients. What I would recommend, there is a woman by the name of Dr. Allison Galvani, who's out of Yale. She does a lot of research work for Medicare for All. Like when you see the Medicare for All savings reports, she did those. And I can connect you. You should have her do some research on the impact on the cost to Medicare versus the availability here. Yeah.

And or, and some people, you know, I don't want to get into politics, but, you know, on Trump R.X, I don't know if it's listed there, but that's one more source as a portal where people can find out that it's available to them. And so those are the two steps I would take because to your point, you just want more people to know what's available. No, it's available and be able to afford it. Yeah. And that's our mission. The only drug that's going to work is the one you're using. And that's not something we typically run into shortages on. either. Okay. At least not so far. So it's literally going generic in Canada next year. Wow. Yeah. I think

people will be going across the order. Yeah, but you're taking the trip, right? But that's always the thing, right? If you're responsible enough to buy multiple months and store it properly, always buy as much as you can afford. There's something I love about the change of seasons. Rediscovering the pieces in my wardrobe that I know I'll reach for again and again. As we head into fall, I'm a special. looking forward to pulling out my Quince, Mongolian, cashmere sweaters. They're the kind of wardrobe staple that makes getting dressed feel effortless, comfortable, timeless, and incredibly versatile. That's one of the things I appreciate most about quince. They focus on the everyday essentials that we actually wear, using elevated materials like Mongolian cashmere, organic cotton,

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It's the best way to support the show. I'm Dr. Sanjay Gupta, host of the Chasing Life podcast. There are probably a lot of people listening who are on these medications and specifically SSRIs, these selective serotonin re-uptake inhibitors. How would they know if they're on the right medication, should they continue to be taking it, or should they start thinking about deprescribing or tapering? How would you talk them through that? If consumer reports called you tomorrow and wanted your appraisal of this product, what would you say? I'm often struck by the times in which people will struggle with that.

That's not very compelling. I mean, if you're going to be putting a molecule in your system, you want to be able to say, this helps me think, this helps me separate from feelings of anguish. It restores my sleep. Listen to chasing life. Streaming now wherever you get your podcasts. This episode is brought to you by Whoop, the wearable health and fitness coach that gives you personalized insights into your sleep, recovery, strain, and overall health so you can empower your day.

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traveling for work, or simply trying to keep up with a busy week. It can help me recognize when I have the energy to push myself and when my body might be telling me it's time to slow down and prioritize recovery. To learn more, head to whoop.com. All right. You had mentioned something earlier that caught my attention. You talked about specialty drugs. We have generic and then we have what is a specialty drug and why does it seem like so many women's health drugs? or specialty drugs.

A specialty drug is whatever a PBM decides is a specialty drug. Okay. That's it. Like literally when you look at a PBM contract for an employer or city state, whatever, it says we are not going to pass through rebates. We're not going to pay this or this or this for specialty drugs. And then separate 500 pages away, it says we get to decide what's a specialty drug. I mean, like a matnib is considered a specialty drug. I don't know what those are.

Amatinev is for CML. Okay. For cancer. Chronic, myelogic leukemia for our listeners. And then Everellimus is for heart rejection medication, right? And literally, they're pills. And pills are easy to make. They're not hard to make, you know.

And so, you know, that's what happens. Now, there's also more complicated ones that are injectables, like a GLP one would be, but hospital administrative drugs, right? They're not necessarily hard. And what you're seeing is you're seeing infusion centers and places that will charge less than a hospital for that medication. But it's really structured just to maximize earnings for providers and the middlemen and to a certain extent the manufacturers as well. So we're going to do a deeper dive into women's health. But before that, how would you fix all this?

Like, you know, you're... I'm working on it every day, right? Yeah, I'm working on it. it every day. But like if you could blow it all up and start over. This is the shark tank hat I put in, right? Because that's what I do. That's what I've done my whole career. This part of this business, this part of this business, this part of this business, here's where I can compete with it. Here's where I can invest in it. Here's where I won't touch it. And that's what's happened here. And by not working inside the system, all those middlemen we talked about, we don't work with them. Because I don't want to be,

there's no way we're ever going to be aligned because they're not ever putting patients first. And, you know, people are like, well, you're a rich guy. You're just trying to make money. No. Like, my next dollar is not going to change my life, but my next dollar might save somebody's life. And that's the way we look at it at a cost plus. So you've talked about women's health. We found some good sound bites. Right now, less than nine percent of NIH grant money, and I know a lot about this, went to women's health over the last decade, specifically to women's health. And you've talked about it as being overlooked and underfunded. Why do you think that is? It's run by men. I hate to keep saying patriarchy,

but I, you know, grew up in the system. I was trained in the system. And it took me, what, 20 years of practice to really, like, be able to take a deep breath and realize how much bias was built into the system. Oh, yeah. Look, as an entrepreneur, I always look to see where things are screwed up because that's what creates opportunity. But most people don't think that way. Most people just go to work, do their job, do the best they can, want to go home, play with their families, the dog, the cat, and that's it. You know, I used to tell, you know, as my early, in my early companies, people say, well, let's listen to our customers. And that's what you're supposed to do, listen. And I was like, no, our customers, this is.

It's not their job to figure out where we're supposed to go next or what's coming next. It's just like the strategy, all right. We saw Dr. Rubin, you know, turned me on to it. I realized it was an issue. Let's get ahead of it. Most people, that's not their job. They don't think about that. They just want to, you know, spend time at home and live their lives and live as best

of life as they possibly can. Right. And when it comes to NIH, NIH grants, the people making the decisions even are like that. Yeah. Right. They just want to go home, right? They're going to take the path to least resistance every same. single time. And that's what happens in medicine in general. That's what happens in government. That's what

happens in most companies. As I said, I think, you know, these CEOs could change all of health care in this country. Literally change it for the better. So we have a better system than overseas. But that's not their core competency. So there, I had mentioned it earlier, this menopause gold brush, right? And menopause seems to have become, and that's what the media is calling it. I'm just happy to the conversation is happening. But this does seem to be a category that investors are getting more curious about and maybe fighting over a little bit.

What do you think is happening here? What do you see in your... People see the opportunity, you know, not so much in the manufacturing side of it, but, you know, using AI, trying to come up with new drugs, drug discovery, repurposing other drugs to see if they're applicable. And the FDA is open. I give them credit, you know,

there's people there, you know, Chris Klomp at HHS really want to do the right thing. And I think some of those things have been accelerated to the benefit of women. So just yesterday, the day that we're filming this yesterday, there was an FDA open hearing on testosterone for women. And, I mean, it went on eight hours of testimony from clinicians, from patients, you know, who have been helped. But, you know, listeners may not realize we don't have an FDA-approved testosterone product for women in this country. I had no idea. Yeah.

And so when we do prescribe it, I borrow the men's version or some people. Right. It's off-label, right? Some people compound it. We use it off-label. But, you know, men need 10 times the amount in general that women do. And so having to titrain the pump can be a little sketchy and having to check levels. I'm excited by this meeting because everyone at HHS and FDA who were there speaking, you kind of got the feel that this was positive and they were, you know, but it's more complicated than that. FDA doesn't make drugs.

FDA approves drugs. What would it take to get a female probably knowing what you know about manufacturing? I mean, somebody's got to make the time and investment to go get all the approvals. You know, we've looked into it, and the FDA typically isn't the inhibitor unless you're trying to make hundreds or thousands of drugs like we do. Then they can get in the way, but not operationally more on a cost perspective. But I think as it comes to light just what the gold rush is, people find ways. Like I've invested in two companies that are trying to figure out ways to get through endometrials. You know, I mean, I've had somebody in my family that we've had to deal with it, other people close to us.

And, you know, it's crazy. It's like almost every woman is going to go through it at some point. And there's no way. Well, it takes seven to ten years to get the diagnosis. Yeah. She goes through years of, oh, you're just crampy, that you're this, you're that. And there are some biologics being explored on. Yeah.

And I've invested, who knows, will they turn out? I'm like, I don't know. I don't understand. this. Here's some money if it helps. Let's see what happens. Yeah. I do, one of the things I think is powerful about social media is all of this awareness and knowledge around. Oh, sure. Female health and where the discrepancies are when we look at female versus male health. When you got into this business and really started digging through, because you've been doing this for four years. And I think, did I read 2018? When I really started getting into health.

You got the pitch. And so it took four years, or math, four years to like build the company and then you've been so eight years in the game. Yep. When you look at male versus female, what do you see? I never looked at it that way. You know, for us at Cost Plus, it was every FDA drug that was approved that we were allowed to sell. We weren't getting access to brands like we wished, and we didn't do controlled substances

just because it's too risky. Yeah, it's a lot. So it was more about how can we offer every FDA-approved medication and do it at the least expensive price. We don't really try to discern if it was for men or women, but just as out of common sense, watching our volumes go, talking to Dr. Rubin, talking to you, you see the obvious, right? We're not dumb. And so, you know, and then that educates us on the wise, you know, and it's good, you know, that women are getting more attention. I went and spoke at a women's health event at the New York Stock Exchange, learned a lot more there. You know, it's just, if I think of it, put

side gender or biology. If I think of it just as a taxpayer, healthy people are a lot less expensive. Yes. You know, and wellness is an issue, but wellness can't cure everything. You know, there are just certain things, man, we're going to get sick. No one dies healthy, you know, and so there, the more we can invest, knowing that it's an investment, not a cost, and the smarter we can be doing it. And probably the harder part is the smart side of it because there's politics involved. But even then, the risk reward is off the charts.

So when women are healthy, they tend to reinvest in their communities. They tend to, their families are healthier. They're making 80% of the health care decisions in the U.S. Well, let's just look at the birth rate. Yeah. If we don't have enough babies and, you know, now metapausal women are a little bit different, but still just healthy women endometriosis.

You know, if we can't deal with that. It's taking 10 years to get her diagnosed. She's losing. And if we can't deal with it, you're losing those years of fertility. And again, not to be political, but just having two daughters. Yeah. You know, and nieces and, you know, and so there's value in that, again, if you put aside the empathy and the human value of it and just looked at it as a business.

And I'm not saying, do that, right? They're both important. But just as a business decision, it's good economics. It saves taxpayers' money, healthier, you know, less. Less burden on the medical system. Less burden on everybody. Less emotional burden. Less burden on families.

Less burden on schools. Less burden on companies. Because if that 10-year point hits and they realize it's endometriosis and you're 30 and working at your job, you're going to HR first. Yeah. Right? Because then you want to find out, you know, what doctors are, am I? to go to, are they any good? What are the circumstances? Can I afford my co-insurance or my co-pay? What's the

availability? Can I go tomorrow? I'm in pain or can I go six months from now? All those things impact everything. So in menopause, in the UK, they measured it, they're measuring it better than here. It 20%, one in five women will leave their job due to untreated menopause. And that's just hot flashes. That's what we know how to measure. We're not talking about the brain fog and the, you know, in the U.S., it's at least 10%. So this is, you're at your peak. You know, you're supposed to be leaning in. You're supposed to be running the company. And all of a sudden, you're taking a back seat. Now, some people leave jobs for good reasons. But, you know, we're losing workforce, well-trained employees to this stuff we're not even treating. Yep. So. And in an AI world, those people are more valuable. You know,

you want people, AI doesn't understand the consequences of its actions. People with experience and domain knowledge do. So my parents' generation, so my dad's passed away, my mom's in 90s, so we're at the end now. But they grew up wanting insurance to cover everything. And they had insurance, they'd worked for it, they were proud of it. But if insurance wouldn't cover something, then they didn't get it. They would go without because it's not worth having this should be covered. I don't think my children, when I talk to them about it, they look at insurance for catastrophe.

The number one cause of bankruptcy in the U.S. is medical. And so my kids look at it as, well, this is something that's going to keep us out of bankruptcy if the unthinkable happens. You know, we end up with these huge bills. And, you know, I think I'm somewhere in the middle. And do you, you know, but what's happening is the older generation, me plus, so I'm I'm 58, they won't go get their medication. What would you say to them? So let's divide medical and medication pharmacy.

Yeah, so just their prescriptions. They're like, well, insurance is going to cover it. Pharmacy is a bigger problem because with medical, if you go to a nonprofit hospital and you don't have the financial resources, and I'm not just talking to the emergency room, right? I'm just talking, if you don't have the resources and there's something endometriosis, whatever it may be, right? They have to offer you some type of payment plan. Most people don't know this. Exactly why I mentioned it, right?

They have to do it, but it has to be a nonprofit hospital. Federal qualified health centers. They have to see you if you don't have a nickel to your name. And so they may not be able to support you or care for you and everything that you're facing, but they can refer you to somebody who can. don't ever not get care. And you're better off not going to the emergency room. Because if you go to the emergency room, they just look at it, well, we have to treat you.

Are you going to die or not? Right. Yeah. Right. And then we're to stabilize you and kick you to the curb. Right. That's an overstatement. But still.

But if you go to a nonprofit hospital and you say, hey, here's what I'm facing. I can't afford it. I'll work on your schedule. Right. Now, if it's an emergency, go to the emergency room. Right. But you have a chance where they're supposed to work out a payment plan. and work with you.

They're supposed to offer charity care in order to get the tax breaks that they get as a non-profitable. That's where that tax breaks. How would a regular person figure this out? Like, okay, I have this medical problem. Claude. Uh-huh. Chat, TPD. Go to whatever your favorite AI is and say, I'm, you know, I've got this.

I really want to see a doctor. I don't have insurance. I don't have coverage. What's the best approach for me to take? will any of them work with me on a plan and see me? And I don't want to go to the emergency room. Okay. If you have it on there, you can type it in there and see what it comes up with.

So let's get practical for our audience as we're wrapping up. Give them some advice, like, on prescription drugs. So first, know your health plan. You know, know what drugs are covered. And can AI be helpful here? AI is less helpful in this because each plan's different and it may not have access. But I would definitely recommend if whatever you have online that's available to you, put that link into your AI and have it just say, hey, I want you to understand all this so I can ask you questions about it. Because the AI will be able to look at all the details and the fine print where your eyes are going to glaze over and you might not see it.

And then you can then ask AI questions. Like, is my estradiol covered? Is whatever it may be, right? What's the price? What tier is it in? Where can I buy it? It'll answer those questions. I mean, I use it.

Does cost plus drugs carry it? All those things I use it for. So that's first and foremost in understanding. But from there, you know, you just got to understand all your options. And I know it sounds. It seems like a lot of work. It's not intuitive, right, to do this, but please use AI. But just don't use one AI.

Okay. Use the interface, the free interface, right, for Claude and Chat GPT and Gemini and ask the same question to each. It's like if you have three friends just sitting there, they're all going to be a little bit right. None of them are going to be 100% right. And so you have to take. Or if you do a search, right, you're going to get three different links. One might be misinformation and you may not know it, right? but having them, you know, ask the same question and challenge your AI.

Are you sure that's right? Don't just presume that it's automatically accurate. So, you know, okay, chat, you BT, I'm not quite sure if this is right. It doesn't matter whether you know or not. Will you check this for me? I want you to be absolutely positive. Okay, Gemini, this is what, you know, my friend said, and they said, A, B, and C, will you check this for me and tell me if they were accurate, meaning the output from

chat to PT and then go to Clod and do the same thing. They're not all going to be wrong. And they all might have a different perspective. They all might give you different. They can fact-check each other. Yeah, they can fact-check each other. And you can use your common sense to make a determination. But they will be able to go and look at the websites of hospitals and say, hey, I can't afford this. This is what my doctor said. I can't afford the- cat scan, this medication, this surgery. And I looked at my insurance and the cat scan was going to be $1,800 out of pocket. Is there somewhere else?

And, oh, by the way, I live in the state of Texas. Can I apply this to my deductible? In Texas, you can, but not for pharmaceuticals. And Indiana, you can for pretty much everything. Tennessee, I think you can too. So using AI as a tool, it's not the end-all-be-all. It's not the final answer on anything. But we know how we are as humans.

Our eyes glaze over when we look at these plants. I don't care who you are. You know, I consider myself marginally smart, and I just like... Any last advice to our listeners? Yeah, go to cost plus drugs.com. You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. You can also find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawslife.com.

Unpaused is presented by Odyssey, in conjunction with good roommate media and longwave digital. This episode was sponsored by Midi Health, the first virtual clinic created for women, by women, for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit join midi.com to learn more.