Combination (Combo) Drugs
What are Combo Drugs?
Drugs that include two (2) or more active ingredients combined into a single dosage form are called combination or ‘Combo’ drugs. Combo drugs sound like a good idea; the patient can take one (1) pill to treat multiple diagnoses concurrently, but these drugs are outrageously priced and are putting a strain on healthcare spending. The drug manufacturers claim that the idea of combining two or more common medications into one (1) specialty pill is convenient for the patient and the prices that are set are based on the value they bring. These combo drugs are overpriced and may be another fraud, waste and abuse stream for pharmacies and prescribers.
What are some examples?
The following are examples of combo drugs:
Vimovo is a combo drug that contains a nonsteroidal antiinflammatory drug (NSAID), Naproxen, and a proton pump inhibitor(PPI), Esomeprazole. It works by reducing pain/inflammation and the PPI reduces the amount of acid in the stomach. Vimovo is indicated for adults who may have symptoms of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
Vimovo® is indicated for adults who may have symptoms of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
The average retail price for a 90-count bottle of Vimovo® is around $2,601 (depending on the pharmacy that is billing). To put this in perspective, below is a cost breakdown of the individual medications used to manufacture Vimovo® respectively:
- 60-day supply of Naproxen 500mg costs an average of about $28
- 30 capsules of Esomeprazole 20mg costs about $31.00.
- Conclusion: two (2) separate medications will cost about $59 compared to $2,601 to treat the same diagnosis.
Duexis® is a combo drug which contains Ibuprofen, an NSAID, and Famotidine, a H2 blocker used to prevent heartburn and symptoms related to acid indigestion.
Duexis® is indicated for the relief of symptoms of rheumatoid arthritis and osteoarthritis and the Famotidine helps decrease the risk of developing upper gastrointestinal ulcers.
The cost of a 90-count bottle of Duexis® is about $2,600 (depending on the pharmacy that is billing the drug). Below is a cost breakdown of the individual medications used to manufacture Duexis® respectively:
- A 90-day supply of Famotidine is about $19.00.
- A 90-day supply of Ibuprofen 800mg is about $25.00
- Conclusion: two (2) separate medications will cost an average of about $44 as compared to the $2,600 bottle of Duexis®.
Why should health plans monitor combo drugs?
The challenges payers are faced with is that these inappropriate medications can be very costly and provide low value. Without any edits in place, these drugs are likely covered by insurance health plans at point of sale. Continuous monitoring, detection, and prevention of these claims is a step to alleviate the risks of inappropriately billing.
What should your health plan expect regarding claims submissions for combo drugs?
- Vimovo® claims for patients with a medical diagnosis for osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis and history of diagnosis involving heartburn, difficulty swallowing, or persistent cough.
- Claims for Duexis® for patients with medical diagnoses for rheumatoid arthritis and/or osteoarthritis and conditions involving upper gastrointestinal ulcers.
What should your health plan consider as outlier utilization for combo drugs?
- Pharmacy claims for combo drugs without correlating medical claims data.
- Non-existent diagnosis history for the indications the combo drug is approved for. See references above.
- Excessive prescribing or dispensing of combo drugs from certain pharmacies, prescribers or among certain members/clusters
How can the Codoxo Forensic AI Platform assist your health plan with identifying emerging risks, trends and other outlier claims for combo drugs?
- The AI engine and detectors identify patterns, volume and frequency across all peer groups and claims allowing customers to identify, analyze and respond to potential FWA and efficacy issues
- The Query tool allows users to build custom queries, tailored to your organizational needs
If you are an existing customer, please contact your Customer Success representative or email@example.com for assistance with this topic. If you would like more information or to setup a demonstration of the Codoxo Forensic Platform, please contact firstname.lastname@example.org.
1. FDA, Approved Drugs Database, Vimovo, Medication Guide, Reference ID: 4707976
2. FDA, Approved Drugs Database, Duexis, Medication Guide, Reference ID: 4465468