Some concerning medication PAR scenarios are beginning to reveal themselves. Our clinical team is identifying them and giving examples.?
- The provider requests an on-formulary medication (formulary has unspecified dosages) with unique, sub-therapeutic, and/or concentrations that are not guideline supported. Thus prior authorization isn’t required.
- Due to their obscure dosages, concentrations, and quantities, they are significantly more expensive (sometimes 10-20x) than guideline recommended dosages or therapeutic equivalents.
- They are often denied or modified to a guideline supported dosage or therapeutic equivalent at Level 1/2 review.??
- These PARs are often appealed to Level 3 by the requesting provider and the determination is often approved, noting they are formulary medications and do not require prior authorization.? The Level 3 review does not consider the dosage or concentration - only that’s it’s on the formulary
- Diclofenac potassium is being requested rather than diclofenac sodium?
- Diclofenac potassium has a faster release than diclofenac sodium - otherwise there is no material difference in the medication.
- Immediate or delayed release makes no difference in dosage frequency.?
- Diclofenac sodium is available in 25, 50, and 75mg tablets that are enteric coated (easier on the stomach) and diclofenac potassium is available in 25 or 50mg tablets.?
- Diclofenac potassium 25mg is $34 - $38 per tablet while the 50mg tablet is around $2.75 per tablet.?
- Compare this to diclofenac sodium dosages - all of which are less than $2 per tablet.?
- Prescribing diclofenac potassium 25mg twice per day is not only subtherapeutic, but considerably more expensive than other options.?
- Medical scenarios may exist to justify the outliers.
- But not paying close attention is costly.
