October 17, 2022

Things Change: The Growing Diversity of Pharmacy Cost Drivers

At one time, the prevailing conversation in workers’ compensation pharmacy management was focused on opioids. Addiction, abuse, overdose deaths – only after a decades-long struggle did healthcare professionals, industry leaders, and regulators come together to create multi-pronged strategies that have led to decreased opioid utilization and associated costs.

Declines in Opioid Utilization

  • Opioid prescriptions decreased 23% from 2012-20171
  • Opioid dispensing fell to a 15-year low in 20202

As workers’ comp continues to move forward from underneath the shadow of opioids, there is no longer a single drug class driving the overwhelming majority of pharmacy costs. Instead, there is a more diverse range of trends to consider when developing pharmacy program strategies, driven by a number of factors including, but not limited to, legislation expanding presumptions for certain occupations, the introduction of new and novel agents on the market, and regulation loopholes that incentivize prescribing behaviors.

High-Cost Oral NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) have long been recommended as a safe and appropriate therapy for pain management associated with workplace injury. Indeed, the use of NSAIDs has grown rather steadily as opioid utilization has decreased, which is not unexpected.

NSAIDs account for 18% of prescription workers’ comp drug payments.3

Commonly used orals NSAIDs include:*

  • Aspirin
  • Ibuprofen (Motrin®, Advil®)
  • Naproxen (Aleve®)
  • Meloxicam (Mobic®)
  • Celecoxib (Celebrex®)

*For the purposes of this article, we are differentiating oral NSAIDs from topical NSAIDs, as they are experiencing different utilization and cost trends.

Cost Concerns

While NSAIDs are relatively safe medications, within such a large class of drugs there can be outlying trends of concern.

For instance, per-claim payments for NSAIDs in workers’ comp were as low as $21 in Massachusetts and Minnesota and as high as $129 in Florida.3 While such differences in spending could be tied to fee schedules, different worker populations by state, or any number of reasons, such a range in spend indicates there are opportunities to lower costs.

A key example of this is present in California, where two low-volume, high-cost NSAIDs – fenoprofen calcium and ketoprofen – are driving up drug spending.

High Cost NSAIDs in California4

Fenoprofen calcium and ketoprofen made up less than 1% of prescriptions combined, but together they accounted for 12.2% of drug spend

  • The average payment for a fenoprofen calcium prescription is $1,487
  • The average payment for a ketoprofen prescription is $1,073

These two NSAIDs are currently exempt from utilization review within the California formulary due to a regulatory loophole. More often than not, a less expensive NSAID can provide the same clinical benefit as these drugs, meaning that a great deal of this spending is unnecessary.

While this particular problem may be limited to California, this is just one example of how a concerning micro-trend can exist within a larger drug class.

Read the article in full at RxInformer.

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