Why Generic Drug Prices Vary So Much Between States

Have you ever filled a prescription for a generic drug and been shocked by the price-only to find out your friend in another state paid a third of what you did? It’s not a mistake. It’s not a glitch. It’s the reality of how generic drug pricing works in the U.S. The same pill, same manufacturer, same dosage-yet one state charges $12, another charges $80. Why? It’s not about the drug. It’s about the system.

It’s Not the Drug, It’s the Middlemen

Generic drugs are supposed to be cheap. After all, they’re copies of brand-name medicines with no R&D costs. Yet in 2025, Americans still pay more for generics than people in nearly every other developed country. The reason? It’s not the drugmakers. It’s the middlemen: pharmacy benefit managers, or PBMs.

PBMs act as intermediaries between insurers, pharmacies, and drug manufacturers. They negotiate discounts, set reimbursement rates, and decide which drugs get covered. But here’s the catch: their contracts are secret. They don’t tell pharmacies what they paid for a drug. They don’t tell patients what the real cost is. And they don’t tell states how they’re setting prices.

In some states, PBMs use a pricing formula that lets them pocket the difference between what they pay the pharmacy and what they charge the patient. That’s called spread pricing. In others, states have banned it. In California, transparency laws force PBMs to disclose their pricing. In Texas, they don’t. That’s why two people with the same insurance plan can pay wildly different amounts for the same generic atorvastatin-one pays $15, the other pays $120.

State Laws Are the Wild West

The U.S. has no national rulebook for generic drug pricing. That means each state writes its own rules. And they’re all different.

Vermont led the way in 2016 by requiring drugmakers to report price hikes. California followed with laws forcing PBMs to reveal their pricing models. Maryland tried to cap prices on certain generics-but a federal court struck it down in 2018, saying states can’t regulate interstate commerce. That ruling sent a chill through other states. Now, instead of directly controlling prices, most states focus on transparency.

That’s why you see big differences. In states with strong transparency laws, patients pay 8-12% less on average for generics. In states with weak or no laws, prices stay high because there’s no pressure to change. Nevada passed a law targeting diabetes drug prices, but the lawsuit behind it was dropped. Why? Because manufacturers and PBMs threatened to sue under federal trade secrets law. The system is rigged to protect secrecy.

Medicaid and Reimbursement Formulas

Medicaid, which covers low-income patients, pays pharmacies based on a benchmark called the National Average Drug Acquisition Cost (NADAC). But not all states use NADAC the same way. Some update it monthly. Others use a three-month average. Some add a fixed dispensing fee. Others don’t.

That means a pharmacy in Florida might get reimbursed $2.50 for a 30-day supply of metformin, while one in New York gets $4.75. The pharmacy has to cover its rent, staff, and utilities. If the reimbursement is too low, they might charge patients more to make up the difference. Or they might just stop stocking the drug.

And here’s the kicker: Medicaid reimbursement rates don’t always reflect what private insurers pay. So a patient on Medicare Advantage might pay $10 for the same drug that a Medicaid patient pays $15 for. It’s a mess.

Competition (or Lack of It)

In cities with dozens of pharmacies, prices are lower. In rural towns with one pharmacy? Prices jump. Why? Because that pharmacy has no competition. It’s a monopoly.

GoodRx data from 2022 showed price differences of up to 300% between neighboring counties in states like Arizona and Georgia. One pharmacy in a small town in rural Georgia charged $78 for a 90-day supply of lisinopril. Just 30 miles away, in a bigger town, the same drug cost $18. The only difference? Population density and pharmacy competition.

Big pharmacy chains like CVS and Walgreens often have better deals with PBMs because they buy in bulk. Independent pharmacies? They’re left with the scraps. And when they can’t afford to stock certain generics, patients pay more-or go without.

Cash Beats Insurance-Sometimes

Here’s something most people don’t know: paying cash for generics is often cheaper than using insurance.

Why? Because when you use insurance, your PBM sets the price. But when you pay cash, you’re buying directly from the pharmacy at their wholesale cost. Services like GoodRx, Blink Health, and Mark Cuban’s Cost Plus Drug Company show you what pharmacies actually pay. In 2023, 4% of all U.S. prescriptions were paid in cash. Ninety-seven percent of those were for generics.

A patient in Ohio paid $42 for a 90-day supply of simvastatin through their insurance. On GoodRx, the same prescription cost $9. In Alabama, a patient paid $110 with insurance. Cash? $14.

This isn’t a trick. It’s how the system works. Insurance companies and PBMs profit from the gap between what they charge you and what they pay the pharmacy. When you pay cash, you cut them out.

The Inflation Reduction Act Didn’t Fix This

The Inflation Reduction Act of 2022 got a lot of attention for capping insulin at $35 a month and setting a $2,000 annual out-of-pocket cap for Medicare Part D beneficiaries. But here’s the truth: those rules only apply to Medicare patients. That’s about 32% of U.S. drug spending.

For the other 68%-people with private insurance, Medicaid, or no insurance-nothing changed. And even for Medicare patients, the savings vary by state. Why? Because the law doesn’t touch PBM pricing practices. It doesn’t force transparency. It doesn’t ban spread pricing. It doesn’t require PBMs to pass savings to patients.

So while Medicare patients might save $18.5 billion by 2030, millions of others are still stuck with the same broken system.

What You Can Do Right Now

You don’t have to accept whatever price you’re given. Here’s how to save money, no matter where you live:

1. Always check GoodRx or SingleCare before paying. Even if you have insurance, compare the cash price.
2. Ask your pharmacist: “What’s your cash price?” Don’t assume insurance is cheaper.
3. If you’re on Medicare, use the Medicare Plan Finder tool to compare drug costs across plans.
4. In states with transparency laws (California, Colorado, Maine, Vermont, etc.), request a breakdown of your PBM’s pricing.
5. Consider switching to a direct-purchase pharmacy like Cost Plus Drug Company if you take multiple generics.

Why This Won’t Get Better Soon

The drug pricing system isn’t broken because of bad actors. It’s broken because it was designed this way. PBMs, insurers, and pharmacy chains make billions from the gap between what drugs cost and what patients pay. They have lobbyists in every state capital. They fund studies that say “prices are fair.” They sue states that try to change the rules.

The FDA approved over 800 generic drugs in 2017-the most ever. That should’ve driven prices down. But it didn’t. Why? Because the middlemen kept the savings.

Until states force transparency, ban spread pricing, and stop letting PBMs operate in the dark, prices will keep varying wildly. And patients will keep overpaying-sometimes by hundreds of dollars-for pills that cost pennies to make.

It’s not about where you live. It’s about who controls the system. And right now, that’s not you.