June 19, 2023

Low-Volume, High Cost Medications in California

The California Workers’ Compensation Institute (CWCI) has published the second in a three-part series of reports that examine low-volume, high-cost drugs in the California workers’ comp system.

The report notes changes in the average payment per prescription for highlighted drugs over a 10-year study period (2012 through 2021), changes in the percent of the prescriptions dispensed as a brand rather than a generic drug, and factors that contribute to the high cost of the medications.

This report specifically focuses on dermatologicals, opioids, and antidepressants.

Dermatologicals were the fourth most prevalent drug category in 2021, making up 9.3% of the workers’ comp scripts and 17.3% of prescription drug payments. While an increase in utilization is primarily driven by inexpensive, high-volume medications, the study notes three low-volume/high-priced drugs that have become dermatological cost drivers.

The first of these low-utilization, high-cost dermatologicals was diclofenac sodium and adhesive sheets (dispensed as Xrylix kits). Average payments for this drug were $4,126. This drug made up 0.3% of dermatological scripts, but 7.2% of dermatological spend.

The second drug was lidocaine/menthol (dispensed in various forms including NuLido gel and Terocin patches). Average payments for these drugs were $1,050. This drug made up 1% of dermatological scripts, but 6.2% of dermatological spend.

The final dermatological noted was diclofenac epolamine (dispensed as Flector patches). Average payments were $577. This drug made up 1.7% of dermatological scripts but 5.9% of dermatological spend.

In regard to opioids, utilization continues to fall, making up 9.4% of workers’ comp prescriptions and 5.8% of drug spend. However, the mix of opioids used to treat injured workers has shifted. The study notes three low-volume high-cost opioids.

The first is buprenorphine, an opioid used to treat opioid-use disorder, which averaged $363 per prescription. Buprenorphine accounted for 5.2% of workers’ comp opioids but 35.4% of opioid reimbursements, ranking it the highest opioid in terms of spend.

The second is tapentadol HCl (only available as the brand name Nucynta or Nucynta Extended Release), an opioid used when other pain medications do not work well or cannot be tolerated. Averaging $590 per prescription, this drug made up 0.6% of opioid utilization, but 6.4% of opioid spend.

The final opioid mentioned is oxycodone, which is prescribed for moderate-to-severe pain. Averaging $145 per prescription, this drug accounted for 5.9% of opioid scripts but 16% of opioid payments.

Antidepressants also saw certain low-volume high-cost medications. While the top four antidepressants made up two-thirds of antidepressants scripts and 42.5% of antidepressant payments, notable outliers consumed a disproportionate share of drug spend.

Vortioxetine HBr, used to treat Major Depressive Disorder, remains under patent and is only available as brand-name Trintellex. Averaging $476 per prescription, this drug represented 1% of antidepressant scripts, but 12.4% of antidepressant payments.

Desvenlafaxine, used to treat major depression, averaged $642 per brand-name prescription, $58-$66 per generic prescription, and $131 per prescription overall. At this time, brand name prescriptions made up 14-15% of prescriptions. Overall, this drug represented 1% of antidepressant scripts, but 3.5% of antidepressant payments.

Bupropion HCl, which is used to treat depression, anxiety, and other mood disorders, saw a 98% generic utilization. While generic prescriptions averaged $25, brand name prescriptions reached $2,614. Overall, the average cost per prescription reached $77. As a result, this drug made up 7.6% of antidepressants, but 16.3% of antidepressant payments.

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