Parity-priced medications are a hidden pricing tactic used by pharmaceutical manufacturers to drive additional revenue – at the expense of unsuspecting payors. Parity pricing occurs when a medication has the same cost per unit regardless of the strength being prescribed. Providers may prescribe the lower-strength version containing more units instead of the higher-strength version containing fewer units. These missed dose optimization opportunities can result in doubled or tripled plan costs.
The Challenge
During a data analysis focused on identifying parity-priced medications, RxBenefits discovered an existing ongoing prescription for a member of a large religious organization in the western United States. The organization averages 4,100 members per month and has approximately 77% benefit utilization among its membership. For the plan year of July 1, 2018, through June 30, 2019, the plan spent $8.46M (net of discount and copay; pre-rebate), with $144.33
average cost per claim and $170.33 plan cost PMPM pre-rebate.
The data analysis revealed that the existing prescription claim for four 140mg Imbruvica tablets was costing the plan more than $49K pre-rebate for each
28-day supply. This single prescription had contributed $11.62 PMPM in plan cost pre-rebate, which equated to 6.8% of the total plan cost for the fiscal year.
The Solution
Identifying the parity-priced medication provided RxBenefits an opportunity to initiate a change for future fills. Our intervention consisted of contacting the provider to discuss dose optimization. We recommended two alternatives for the member’s Imbruvica medication regimen, one option consisting of four 140mg capsules and the second option for one 560mg tablet:
We also requested an audit of the dispensing pharmacy to confirm that previously dispensed prescriptions adhered to the prescriber’s original intent. The audit was designed to determine if the provider indicated a specific dosage form and strength on the prescription, and to verify that the pharmacy dispensed the medication according to the prescription.
Overall Optimization Results
RxBenefits’ analysis and intervention efforts helped the organization limit its exposure to unnecessary spending and lower its pharmacy plan costs. We successfully optimized the dose and redirected the high-cost medication to a lower-cost option.
The pharmacy audit revealed that the dispensing pharmacy correctly filled the prescription. After our communication, the provider canceled the original prescription and submitted two new prescriptions to the pharmacy, providing a choice between either modified regimen. The pharmacy and member chose Modified Regimen 2 of a single, higher-strength tablet.
