Rapid Response: How Cost Plus Drugs is revolutionizing pharma, with CEO Alex Oshmyansky

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Join us at masters of scale dot com slash apply twenty six. That's mastersofscom slash apply. Twenty six. One of our initial big challenges was just getting the pharmaceutical companies to work with us, because the big cartel basically says, don't do business with cost plus drugs, or we won't buy your product anymore. They're not supposed to, it's grossly anti-competitive, but everyone tells us they do. I saw Mark Cuban had a public Gmail and I was like, eh, can't hurt. I shot him a line, and surprise, surprise, Mark is Smanic. He's incredible on email.

But yeah, he got back in like five minutes and we had a brief dialogue and he invested a small amount of money to start with. Now he's a true operational co founder. He wants to You know what he says is F up the industry. That's Alex Oshmiansky, CEO of Cost Plus Drugs, which he co-founded with Mark Cuban. Cost Plus Drugs received the 2024 Rapid Response Award at this year's Masters of Scale summit for quickly and effectively disrupting the pharmaceutical industry.

Alex has an amazing backstory from heading to college at age thirteen to getting advice from OpenAI founder Sam Altman to cold calling Mark Cuban. But what's most impressive is how he's managed to dramatically cut prescription drug prices, something decades of public policy have failed at. So let's get to it. А Боб Сафін. And this

is rapid response I'm Bob Safian, and I'm here with Alex Oshmiansky, the co-founder and CEO of Cost Plus Drugs. Alex, thanks for thanks for joining us. No, thank you for having me. Cost plus drugs sells Thousands of drugs. At cost.

Plus Fifteen dollars for shipping. Right? That like that's the plus part. So we do uh Our true cost, and that's the big, you know, innovation if you want to call it that about our company. We reveal what we purchase all the drugs for. We had a fifteen one five percent margin for ourselves. Uh

five dollar fee to pay our pharmacist, five dollar shipping and handling, and then that's the total cost of the drug. I'm on a statin. A statin prescription can cost Two hundred dollars somewhere else. Five bucks. Like How do you make that work financially?

One of the big things that's unknown about our pharmaceutical distribution chain is there's effectively a cartel of three companies. The so called pharmacy benefit managers. That the way they do this is very, very complicated, but the bottom line is they buy all the drugs, they mark them up as much as they want, and then they resell them. They accomplish that through effectively being a form of payment processor for insurance companies. But yeah, if you just go around the system. Sometimes the price reductions can be radical.

You know, it's estimated at least thirty to forty percent of all drug spending goes to the pockets of the pharmacy benefit managers. They're drugs we sell on our site. for twenty, thirty dollars for a month supply. that if you tried to get it through your insurance and you had a high deductible plan

You would be asked to pay three to four thousand dollars out of pocket. Yeah, it's insane. It's criminal. Uh yeah. And that's not hyperbole. Uh they will say actually the list price of this drug is ten thousand dollars for a month supply. So actually we're getting you an amazing deal at Three thousand dollars. That's a seventy percent discount. How amazing are we? Meanwhile, if you go to the drug manufacturer and just say, Can we buy this from you? Yeah, the true price is closer to twenty to thirty dollars for that same month supply.

And yeah, very proud that actually exposing that practice the Senate actually questioned the CEOs of the big PBMs on it. And uh now there's a office of the Inspector General investigation about that particularly egregious like hundred thousand X price increase practice. You and I were talking earlier, you're you're a physician. You became animated about these cost issues. As a physician yourself, like how did this sort of pop up to you to be like, This is something I'm gonna

Turn my life towards. I think every single physician has had patients injured by not being able to afford their medications, family members. I'm a radiologist by training, but I was working with a pulmonologist on a research project at one point and uh You know, one day he came in and sensed'cause two of his patients had died over the same weekend. They both needed a drug called Bozentin, which was then generic, long off patent, but still cost ten thousand dollars for a month's supply.

And you'd think that'd be enough to get me sort of started on this, but Kind of a straw that broke the camel's back. Uh do you remember this character, Martin Shkreli, the uh the pharma bro? Yes, yeah. He he ended up uh spending some time behind bars, yes, for unrelated securities fraud, but you know, in retrospect Maybe more to lower drug costs than anybody else by starting marking me on this track. Got you. Yeah, and it turns out he's a very, very small fish in a much larger pond of people taking advantage of people. But yeah, that was the sort of triggering event.

Yeah. Now Costplus Drugs is officially called Markbin's Costplus Drugs. You came up with this idea. You didn't know, Mark? And you just sort of Cold

Call, email. Can you break down this moment and experience for us? So originally started the company actually as a five oh one C three nonprofit. I went out sort of trying to raise funds for it for the better part of three, four years and failed spectacularly. Did not raise a dime beyond what I put in myself. Eventually I applied to Y Combinator for financing the interview committee. Uh actually Sam Altman was on mine at the time. Sam said, We like what you're doing. We'd like to get behind it.

Do not think you'll be able to raise enough as a nonprofit. If you reincorporate as a public benefit corporation, so you know, for profit company but with a registered public mission with the state, we'll invest in you like we would in any other company. And after three, four years of no success, I was like Okay, whatever, let's give it a shot. I'm a little bit embarrassed now to say I took corporate governance advice from Sam Alfman.

It worked out in my case. I was able to raise a a small seed round, uh a little over a million dollars, which, you know, not a lot of pharma dollars, but enough to get kicked up and off the ground and Yeah, just totally on a whim a couple of months after that. I saw Mark Cubin had a public G mail and I was like Can't hurt. And I shot him a line and surprise, surprise, Mark is manic. He's incredible on email. He does respond to everything. Yeah. We shouldn't say that to everyone that's on here,'cause he does he doesn't mind. M Cuban at Gmail. Like he will he'll get back to you. He's

I have no idea how he does it because I'm not that good on email. And like what excuse do I have? Like But yeah, he got back in like five minutes and we had a brief dialogue and he invested a small amount of money to start with, and obviously became much more invested on several different levels. Yeah, effectively the company became a very different thing after Mark got really heavily involved and Now he's you know a true operational co founder. He's not just kibbitzing from the sidelines while he's doing shark tank? Like, No, he's taking customer service calls, like uh seriously. Like he is a manic workaholic. Like any time I email him about any issue, day or night, six in the morning, two AM within Five to ten minutes there's a response and

Yeah, he is deeply into weeds on everything from like website design, coding, uh to our manufacturing plant and operations. He's communicating like every hour about pretty much everything that happens. He wants to you know what he says is F up the industry. So you wanna do that too. You're just not willing to use those words. I ca I'm not a billionaire. I can't get away with it. But we get letters, emails every day of from people who are like, Hey, I was having to skip meals to afford my medicine. I thought I was gonna die'cause I just couldn't get my chemo. I thought I would have to sell my house.

real people who they were being asked to pay three thousand dollars out of pocket For their chemotherapy, for their multiple sclerosis medication, and suddenly we can offer it for twenty dollars. Now you started two years ago, right? You expanded to begin manufacturing your own drugs, so not just buying from manufacturers. Why did you make that decision and sort of how

hard was that pivot, that change for the company to go into manufacturing. Yeah, actually the manufacturing was a piece of it from day one. 'Cause we always assume to get the drugs at a low cost you know, the system's so entrenched we're gonna have to make'em ourselves. Mm-hmm. And actually The direct to consumer mail order piece was kind of an afterthought. Uh, believe it or not. Uh because we were like, hey, this is a thing that's relatively easy to do compared to setting up our own manufacturing

So let's do this first. Yeah, let's just do it on the side. You know, it'll be a public service'cause there's, you know, these patients that are fairly small communities that need these ultra expensive medicines that we can reduce the cost ninety nine percent. Why not? Let's let's and we figured it'd be fairly limited. We launched it in January of twenty twenty two and it just exploded faster than I think any of us could have predicted. To your point on the statins, actually one of our top selling drugs at first was generic rusaba statin, and that kinda blew our mind.

It's a very cheap drug. Like why are we selling so much of this? And it turned out, yeah, one of the big PPMs was adjudicating it at two hundred dollars for a month's supply. A drug that costs literally a penny a tablet. Yeah, now we have millions of people who are customers of our direct to consumer site and still Growing as fast as we can keep pace.

Did you ever think like, Oh, you know what? Maybe we don't need to do the manufacturing. Like maybe we can just keep riding what we've got going. We've got product market fit. Like, let's go. We actually have four different business lines. Sort of the grand scheme is that I like to say we use vertical integration for good instead of evil.'Cause anywhere we need to fit into supply chain to fix the problems, we can sort of fit in there. So we have our our manufacturing operation and there we're very focused on drug shortage. So products that you can't get anywhere else. So I just came from the International Society of Pediatric Oncology Conference.

And they estimate that there's a hundred twenty thousand children who die a year from not being able to get their chemotherapy. Around the world? And the thing is the market is so distorted, the price of this drug is generally pretty cheap. It's needed in relatively speaking small quantities, so nobody wants to make the drug. So I like to say that our manufacturing makes the drugs that nobody else wants to make. Some uh manufacturing operators were like, Oh, let's do this because there's a market for this. You're kind of doing it the other way around. Like if there's already a market and there's already a manufacturer, we don't have to worry about that. Exactly. We worry about the places where that are being neglected.

Exactly. So we use uh robotic technology that uses what are called single use disposable flow paths, which enable us to pivot from making one product to another very rapidly in principle within four hours. And we actually just got a grant from DARPA to take that technology, augment it with AI, miniaturize it and kind of put it in a pod. So we can actually rapidly scale

our manufacturing abilities around the world. And can put one of these automatic sort of manufacturing pods anywhere that there's a drug shortage. And that's sort of our initiative for the next twelve to eighteen months. And when you talk about these robots, I don't know, people in their minds could think of, you know, robots from Hollywood movies, right? Like what are the are these robots you meet? Are they like how how big are they? Are they in their own rooms? They're uh in a hermetically sealed chamber. So these are robot arms when you see the videos of car factories, kinda like those. Mm-hmm. But they have to operate under s conditions of perfect sterility. So they're actually in a sealed chamber that gets periodically sterilized by vaporized hydrogen peroxide.

So it's very neat stuff that they make these uh robots that can operate under these conditions that can mass produce medications at scale. You're a physician. You're not an engineer. Like I so but you're now in sort of the robot business manufacturing business. I mean it's not new to have to Master. Yeah, and it's a lot of fun. Uh so when I was growing up I was actually

Being fast track towards being a a high energy particle physicist. Yeah, so I started college when I was thirteen and was meant to be a string theorist, essentially. Took a hard left turn at the last minute. I I remember looking at a Uh with all the wisdom of like a seventeen year old, you know, like the journal Nature had a cover story about I think it was a string theory, M theory like concept that the universe is a twenty six dimensional soccer ball. And I was like, Okay, this is going nowhere. I I wanna do something that's a little bit more substantive. I did wind up doing an MD PhD, the PhDs in uh applied mathematics.

And yeah, actually now I've Gone far down the like Like everybody else has down the AI rabbit hole. Well, I I don't know everybody. I it sounds like there's a lot that happens between your ears that my that may not be able to happen between mine. Yeah. Um how much Of the automation.

And the technologies like AI are about Making the cost low enough? That's a component of it. A large part of it is just being able to get the product out the door fast enough because the robots are just faster from an operations perspective. So we do use vendors, uh we don't own the distribution robots ourselves. We use uh subcontractors, but they also have robotic pharmacy systems that they use. It's all about then speed. Even if you might have to invest a little more in the robotic

Equipment to begin with. That's in the service of speed. Exactly. We were struggling, I wanna say late twenty twenty two,'cause we were experiencing twenty, thirty percent month over month growth for a prolonged period of time, which is You know, they tell you scaling is hard. It's

Yeah, it's a cliche for a reason. Like it it really is challenging. And you know, there was a period where, you know, it was like a week or two delay with prescriptions going out and we were just scrambling to keep pace. Which now we're in a much, much better place and the prescriptions go out in a day and a half on average. The robotics, the automation really helps just operationally keep pace with what has to happen. Let's just pause for a moment. String theory, not my forte.

course neither is sterilization of robots via vaporized hydrogen peroxide. Alex makes remaking the drug industry sound simple and logical, but he's done more than build a better mouse trap. After the break, we'll dig into how he's re-engineered a marketplace and turned adversaries into allies. Stay with us. Humans will never be more intelligent than AI.

There can be two types of companies. Those were great at AI and those that went out of business because they weren't. How do we build a future? That is human centered. I'm Rana El Calyubi. And on my podcast Pioneers of AI, we answer that question and so many more.

As an AI scientist, entrepreneur, and investor, I know what it takes to build AI that works for everyone. Every week, I sit down with the pioneers shaping our future. And we take you behind the scenes of the AI that's transforming our lives. Find pioneers of AI wherever you tune in. Hey listeners, Bob here. If you listen to Rapid Response on Masters of Scale, you may be missing half the show because every Friday we release a second Rapid Response exclusively in the Rapid Response feed. The guests and topics are just as compelling and timely. From Ford CEO to NASA's administrator to the lessons from The Devil Wears Prada. It takes about 10 seconds to find, just search rapid response wherever you listen to podcasts and hit follow to make sure you never miss an episode.

I hope to see you there. Before the break, we heard CEO Alex Oshmiansky talk about how and why he launched cost plus drugs. Now he talks about the company's consumer demand flywheel, what people misunderstand about Big Pharma, and how he balances patience and aggression. Let's jump back in. Getting the word out that you

Had this. new channel that people could get their medications at much cheaper costs. Was that something you invested a lot in, or sort of happened organically? Zero dollars. Zero dollar marketing spend. You know, of course we have Mark and his platform, but honestly what drives our growth is just word of mouth.

So we tell all the vendors that come onto our platform, all the pharmaceutical manufacturers The exact same thing will happen. We'll we'll sell zero of your medication for like A month or so. And then we'll sell out out of all of it in a day. Then it'll scale from there and what we find triggers those events is social media.

Like someone in their Facebook group for chronic myelogenous leukemia. will realize, hey, I can get thirty dollar a matnib instead of two thousand dollar a matnib. through Costplusdrugs.com Delpost. And then suddenly it'll spread like wildfire through that specific community. So we see that pattern happening again and again and again. So it really is all just driven by word of mouth. Hm. Manufacturers. They have you as a customer.

They have the pharmacy benefit managers as a customer also. Do they get pressure to like oh Don't give it to those guys. Just I'm right? Like do they try to get locked up? Oh no, I've been told over and over again, um, you know, one of our initial big challenges was just getting the pharmaceutical companies to work with us. 'Cause the big cartel basically says like don't do business with cost plus drugs or we won't buy your product anymore.

They're not supposed to as grossly anti competitive, but everyone tells us they do. So the first drug we had was actually in twenty twenty one uh product called albendazole, which was a antiparasitic agent. Uh sold for like two hundred fifty dollars a tablet. We were able to get it for like five dollars a tablet. But the company didn't want to be associated with us. They said we'll sell it to you, but you have to put your own private label on it. That went really well and that it encouraged three other companies to give us a hundred products that we could sell under their own name. They were willing to take the risk.

And yeah, that's When the company properly launched in twenty twenty two. what we had to sell to the pharmaceutical companies for the longest time is, you know, the cartel is kind of a paper tiger, like they need you more than you need them. And the irony is like we're a small company. We don't have the negotiating leverage. We actually pay more.

For the drugs. Like pharmaceutical companies. Like per pill. Yeah. We act the pharmaceutical companies actually make more money selling through us. than they usually do. So one of the questions we get a lot is Well won't this take away from research and development, actually, if you drive down to drug costs.

No, ironically, in this new model of transparency Without all these mysterious actors obfuscating the true price of the drugs, the pharma companies wind up making more. You mentioned this earlier. There's government inquiry into drug prices. Kinda seems like that stuff. comes and goes, you know, there are things that happen and has there been any real progress?

I Don't think that policy change, regulation, legislation is really gonna help? As soon as they implement the policy that's designed to Eliminate some bad practice. The PBMs have already moved on. Generally

Everything that's on discussion now for PBM reform on Capitol Hill is addressing the big scams that were in place five to seven years ago. So really what we think is the solutions is private sector reform. Which is if the big fortune five hundred companies, fortune fifty companies move away from the big PBMs and go to the smaller competition. Like we think the industry will Suddenly. have to reform of its own accord.

So we have this weird coalition of people we help, which is the most indigent members of society. But also kind of the most powerful.'Cause who pays for most of the drugs at the end of the day. Right. It's just this stuff is so complicated, it's so convoluted. That like, you know, why would Mark Zuckerberg have to know about like H

Employees' pharmacy benefits. He has other stuff to worry about. Right. No, that someone else takes care of it. Yeah. And then you hire a consultant, and the consultant gets paid on the back end by the PBMs, like basically there's this whole corrupted system to ensure that the big PBMs are kind of locked into place. And if you can break that up from the private sector, that I think is the more meaningful reform. The public narrative about Big pharma sort of like big pharma is bad. You know, it's ripping is ripping you off. It's doing th and if I'm hearing you right, you're sort of like it's not big pharma. It's just these PBMs that are that are in the middle. The big pharma certainly no no angels, though like they're not innocents in all of this, but

At least they make the drugs. You know, when I talk to like a big pharma CEO, they're like You know, we do all the R and D, we take all the Flack from the public,'cause they know what a pharmaceutical company does. Their eyes have glazed over by the time you say pharmacy benefit manager. Like we take all the legal liability, we do all the manufacturing, which I can vouch for is hard. Like Why did these guys get thirty percent off the top? Like that's nuts. There's actually no love lost between pharma and the pharmacy benefit managers. And in some ways the wrath against

Big pharma is kind of unfair. Like insulin's a great example, actually. When they came up with the recombinant insulins, they were very expensive, but the price did drop pretty substantially. And Big Pharma was selling insulin for about twenty dollars a vial. But there were people literally dying'cause they couldn't afford their insulin at the list price of four hundred dollars a vial. Yeah, that was pretty much entirely the fault of the PBMs. Mm-hmm. Despite or or I should say while you're running the cost plus drugs, you still haven't given up

Practicing radiology, is that right? You still do that for uh a shift every every week? Why is that? Uh, maybe it's just some cost fallacy. Like it was a long time to getting to be a doctor. Not giving that up. Uh but yeah, no, uh I do find it rewarding. Uh I find it grounds you,'cause you know, as an emergency radiologist, you're making snap r life and death decisions and a rapid pace. And it I find it breeds discipline in decision making. As a founder, you want to make decisions, you want to stick to it. If there are bad consequences, so be it. The same thing applies to medical decision making. You know, there's a quote from Sir William Osler, one of the founders of modern medicine. that they taught me in my surgical internship orientation, which is

The essence of medicine is the assumption of responsibility. Which is, you know, you have to take ownership for the patient. Like you have to make the decisions and live with the consequences'cause Most of the time not making a decision at all is worse. Mm-hmm. So yeah, I find it just breeds discipline that I have to do that within the company as well. It's like a weekly reminder about like sort of what's most important. Yeah, exactly. Exactly. I read that while you were in residency as a doctor, you attended night school to study law, too. Is that right? I did that for one year. Yeah. Why? I just thought it was neat. I just thought it was interesting. I'm exceptionally nerdy. Does it does it come in useful at all?

Oh yeah, it's super useful. The first year curriculum was like contract's law and Civil procedure, which actually for business is pretty helpful. What's a force majeure clause? All these sort of like legal terms of art that you don't get intimidated by anymore. I had previously run a startup and gotten kind of fleeced by lawyers. And I was like, I wanna at least like No enough. To say when like, Okay, it's cool, we don't need to get charged any more legal bills.

So this is something else I read that Until the fourth grade You were in special needs classes? That's right. It seems a little hard to hard to believe given, you know, obviously all the things you've achieved since then. I'm from Denver, Colorado originally, but my parents are from the former Soviet Union and I grew up speaking only Russian. Mm-hmm. So when I went to school I was put in a second language English class.

Which was taught in Spanish. So I was a a little bit slow on the pickup. I remember it was me A kid who spoke Arabic, Jabron, and uh Christian who spoke Tagalog, who's a Filipino, and we just kinda like Shrug our shoulders at each other in the back of the class, like what's what's going on here. And eventually I had one of these life changing teachers in the fourth grade uh who was like, Oh, maybe he's not slow, maybe he's just Russian. Yeah, he uh took extra effort to like help me learn English and speak it without an accent and yeah, eventually he was like, Okay, well now we've gotta place you, now that you speak English.

You know, take this math test. Take this math test. Take that. Oh, you're not slow, you're a genius. I don't know. Yeah, it's amazing how much of your life trajectory is just what people tell you you're good at when you're eight years old. Yeah. A friend of yours said that your superpowers is being able to put up with tedious bureaucracy. How much of what you've learned and applied is about patience and how much is about Like aggression.

I'd say a lot more of it is about patients. You know, medicine specifically and healthcare broadly is a lot of entrenched bureaucracy. when you see companies like uh Amazon or Google attempting healthcare initiatives and they flame out and they go away after a little bit, you're kinda like I know what happened here. They got caught in a million pages of red tape. And just decided to move on to the next project. So A lot of it is just putting up with like

We have to file form fifteen B and subsection C, in order to get approval from, you know, this city regulatory body before we go to the state regulatory body. I could see someone who clearly picks up on a lot of new things quickly. Feeling a little bit like, God, this is so stupid. Why is this done this way? Yeah. I'll take that credit for that as my superpower of just being able to put up with it. Uh a very different time horizon than Technology moves. When you see how far Cosplus drugs has gone. It's gone pretty far pretty fast.

And where you sort of hope it will land. Like how far along that journey are you? Are you thirty percent along the journey? Are you three percent along the journey? I think three percent is fair. Like we've got a we've got still got a long way to go. But yeah, I remember Sam was just starting open AI around the time that I was in Y Combinator. And he had to think that like it's hard for humans to conceptualize scaling laws. Like how quickly if you grow exponentially, like how quickly that winds up adding up over time, like the human brain's just not program to be able to understand that. And yeah, that's very much happened with us and I think we're still on that

exponential trajectory, not just of metrics, you know, volume or whatnot, but also of the amount of substantive change we're making to the systems. C V S CareMark, one of the big three PBMs, put out a cost plus program. And I was like ah Subtle. They even use our like company colors, which I was like Nice.

So yeah, they definitely feel like they have to respond to us and yeah, hopefully it does drive more long term meaningful change. My view of it is that in classic economic theory. Where you have an opaque market, the winners are not the buyers or the sellers. They're the people that broker information in between. Mm-hmm. You see that happening in healthcare like crazy, where the opacity is a feature, it's not a bug. 'Cause they're able to create enormous arbitrage opportunities based on the opacity in the system. So I think as actors on both sides of that, the pharma companies, the hospitals, the physicians, the providers.

Realize hey Actually we've been told that hiding our prices is good for negotiations. Actually it's just the opposite. We're getting taken advantage of. And as that sort of mind frame and knowledge kind of spreads, hopefully it'll bring you know, more meaningful transparency to the status quo. What's at stake for you and Cost plus drugs right now.

Right now our big program is getting uh not just the generic manufacturers to work with us, so we have pretty much every generic drug available now. The next step is uh getting the big branded companies to work with us as well. We're making inroads there. Johnson and Johnson, Bear, Pfizer on various products. So it's moving along. We also sell drugs in bulk to health systems, institutional clients, independent pharmacies, doctors clinics, offices, health systems. We just started that earlier this year.

And actually that's our fastest growing piece of the the business at the moment. And I think we've got some very exciting stuff in the background that, you know, can't talk about quite yet, but hopefully in the next three to six months we should be able to make some more major announcements as well. Well, Alex, this is great. Thank you so much for sitting down to talk about thank you so much, Bob. Appreciate it. You don't have to be a genius like Alex clearly is to glean great insights from his story. I love that he's curious about new technology, from robotics to AI. I love that he's fearless about asking for help, whether from Sam Altman, Mark Cuban, or a healthcare CEO. And I love how he blends opportunistic action with long-term vision.

Costplus Drugs didn't plan on being a direct to consumer business, but when demand took off, he went with it. At the same time, he hasn't stepped back from his big picture mission to transform the drug industry. That mix has enabled both momentum and impact. There's clearly more to come too. We'll keep watching and sharing with you what we learn. I'm Bob Safian.

Thanks for listening. Rapid response is a Wait What original. I'm Bob Safian. Our executive producer is Eve Tro. Our producer is Alex Morris. Assistant producer is Masha Maku Tonina. Mixing and mastering by Aaron Bastanelli.

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