Quarterly Drug Update: Evaluating Combination Medications

Learn what combination medications are, how they impact workers' compensation claims and what major combination medications your program should evaluate.

Pricing for prescription drugs is a topic of much discussion. Combination drugs are often under scrutiny as a common practice for manufacturers to create new brand medications. While these combination drugs are effective, they may be more expensive and no more effective than their separate generic components that typically come at a significantly lower Average Wholesale Price (AWP). AWP is the average value of a drug when sold to customers such as physicians and pharmacies, and is typically used to calculate the cost of a particular drug.

However, prescribing in workers’ compensation is multifaceted. It is important to understand why physicians and patients might want the combination brand and how it can impact the overall claim cost, and then identify some commonly used combination medications you may want to evaluate in your clinical program.

Read our previous quarterly drug update about generic medications.

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What are combination medications?

Combination drug therapy is the use of two or more fixed-dose medications in a single-dose formulation (e.g. tablet or capsule). It can also be the use of two separate drugs to treat a condition (e.g. two different types of medications for blood pressure). Combination drugs differ from compound medications. Compound medications are personalized for each patient, in which a pharmacist or company uses one or more ingredients to make a different product. Most compound medications are creams, lotions or solutions, whereas combination drugs are typically tablets or capsules and are not personalized for a patient. To learn more about compounded drugs, click here. The prescribing of combination medications goes beyond mere cost; some patients may have a medical necessity for taking one pill over several. Prescribing behaviors are complex and each patient has unique needs. However, it is important to evaluate whether these medications are medically necessary for all claims and if there are alternatives that can provide the same drug therapy.

Are combination medications better than their generic alternatives?

The idea of taking one medication instead of two (or perhaps several) is certainly compelling. Reducing the number of pills a patient has to take may increase likelihood that the person will take all needed medications, especially if taking multiple pills is difficult for that person. However, in terms of efficacy, combination medications typically offer no advantage over their generic ingredients. For instance, taking one Duexis® (famotidine 26.6mg and ibuprofen 800mg) brand tablet is therapeutically equivalent to taking each medication separately, one famotidine 20mg tablet and one ibuprofen 800mg tablet.

Why do combination medications create an issue in workers’ compensation?

As with many concerns in the workers’ compensation industry, stakeholders have to consider why costs are significantly higher than expected and if these high costs are justifiable. When a combination medication is created, the price for the drug can inflate dramatically. Considering that the efficacy of this combination drug is often no different from its generic alternatives, this price often reflects the convenience of taking just one medication instead of several. For instance, famotidine and ibuprofen together cost under $100 for a 30-day supply while their brand name Duexis® AWP is $2,978.64 per month. When building out your clinical program, how can you recognize where these combination drugs might be impacting your business? The first step is to identify the most commonly used combination drugs and their generic alternatives. Let’s look at which affect the workers’ compensation industry most often.

Duexis® (famotidine and ibuprofen)

Duexis is a combination of ibuprofen (800 mg) and famotidine (26.6 mg), available in a tablet. Both famotidine and ibuprofen have been available in generic form for years; they are available as over-the-counter medications and are relatively inexpensive. Famotidine is taken with ibuprofen to lessen stomach upset, since famotidine is an H2 receptor blocker and reduces stomach acid. As stated earlier, Duexis® can cost nearly $3,000 for a one-month supply, while the same dosage of ibuprofen and famotidine together cost less than $100. With this stark difference in pricing, why might some prescribers opt for Duexis® over its generic counterparts?

Why might some prescribers opt for an expensive combination medication over its generic ingredients?

Part of this may have to do with lack of awareness of available generics as well as consumer perception of generic drugs. Although the FDA requires that a generic drug be bioequivalent to its brand name counterpart, stigma still exists about the efficacy of generics. A 2015 review published on the US National Library of Medicine, National Institution of Health found that, of the population in the studies reviewed, “laypeople were significantly more likely to view generics as less effective than branded medications compared to doctors and pharmacists.” Additionally, the study concluded, “These results suggest that there are a significant number of laypeople, doctors and pharmacists with concerns about the efficacy, safety and quality of generic medicines.” This perception may be perpetuated by messaging around the combination drug. For instance, Duexis® packaging includes wording from the FDA: “Do not substitute Duexis® with the single-ingredient products of ibuprofen and famotidine.” This sentence does not explain why the two generics should not be substituted, but a look at the FDA trials conducted by the manufacturing company may provide some insight. In the study to show the efficacy of Duexis® in preventing NSAID-related ulcers, researchers compared Duexis® to ibuprofen 800mg alone. Famotidine, which is that needed stomach protectant, was not included. Whether or not the prescribing of a combination drug is related to one of these reasons, it is important to recognize which combination medications are most often seen in workers’ compensation.

Combination medications that impact the workers’ compensation industry:

Vimovo®

• AWP = $2,978.64
• Generic alternatives esomeprazole and naproxen cost in total around $53

Treximet®

• AWP = $1,160.68 for 9 tablets, which equates to $129 per tablet
• This combination drug is now available in generic form for approximately $844.80 (9 tablets; $94 per tablet)
• When purchased separately, sumatriptan and naproxen cost about $236.13 in total

Reprexain®/Ibudone®/Vicoprofen

• All three of these medications contain the same ingredients: hydrocodone and ibuprofen
• Reprexain® AWP = $536.48 for 120 tablets
• Ibudone® AWP = $157.90 for 120 tablets
• Vicoprofen® AWP = $535.60 for 120 tablets
• Generic ingredients AWP = $91.76 for 120 tablets

Nuedexta®

• Nuedexta® has one FDA indication only. It is approved for PsuedoBulbar Affect (PBA), a medical condition that causes involuntary, sudden and frequent episodes of crying and/or laughing in people living with certain neurologic conditions or brain injury.  In the Workers’ Compensation industry, we have seen this drug prescribed off-label.
• AWP = $1,317.60
• Generic ingredients dextromethorphan and quinidine = $13.89 total

Yosprala®

• Yosprala® is indicated for patients who require aspirin for secondary prevention of cardiovascular and cerebrovascular events and who are at risk of developing aspirin associated gastric ulcers.
• AWP = $197.82
• Generic ingredients aspirin and omeprazole cost $20.31 total

Conclusion

Combination drugs can sometimes be medically necessary in a claim. However, it is important to evaluate where generic alternatives can be appropriately substituted. In monitoring drug costs and appropriate therapy, combination drugs should be one area to track in any clinical program.