Combo Generics vs Individual Components: The Real Cost Difference

Imagine you’re on two medications - one for blood pressure, another for diabetes. Your doctor hands you a single pill that combines both. It’s convenient. But how much are you really paying for that convenience? In the U.S., many patients are being charged far more for these combo pills than they’d pay if they bought the same ingredients separately as generics. And the difference isn’t small - it’s often hundreds of dollars a month.

Why Combo Pills Cost So Much More

Fixed-dose combinations (FDCs) are pills that pack two or more drugs into one tablet. They sound smart: fewer pills to remember, better adherence. But here’s the catch - when one or both of those drugs are already available as cheap generics, the combo pill often costs 10 to 15 times more than buying them separately.

Take Janumet, a combo for type 2 diabetes. It contains sitagliptin and metformin. In 2016, Medicare paid an average of $472 for a 30-day supply of Janumet. Meanwhile, generic metformin? At Walmart’s $4 program, you could get a month’s supply for $4. Even if you paid full price for the brand-name sitagliptin (which was still under patent), you’d be looking at under $100 for both drugs separately. Yet the combo cost nearly five times that.

This isn’t an outlier. A 2018 study in JAMA Internal Medicine found that Medicare spent $925 million more in 2016 on 29 branded combo drugs than it would have if doctors had prescribed the individual generic components instead. For the top 10 most expensive combos, the potential savings were $2.7 billion. That’s not a rounding error - that’s enough to cover free prescriptions for millions of seniors.

The Math Behind the Markup

Pharmaceutical companies don’t price combos based on the cost of ingredients. They price them based on what the market will bear. IQVIA’s 2022 analysis showed that branded combos typically cost about 60% of what two separate brand-name drugs would cost. That sounds like a discount - until you realize that generic versions of those same drugs cost 80-85% less than the brand names.

So if two brand-name pills cost $200 total, the combo might be $120. Sounds fair? But if you can buy the same two drugs as generics for $15 total, that $120 combo is a 700% markup. And in many cases, that’s exactly what’s happening.

The trick? One drug in the combo is still under patent. The other is generic. The manufacturer uses the new drug to justify the high price, even though the old one is dirt cheap. This is called “evergreening.” It’s legal. It’s common. And it’s costing taxpayers billions.

Real-World Examples That Shock

Here are a few real cases from Medicare data:

• Entresto (sacubitril/valsartan): Used for heart failure. Brand combo costs about $550/month. Generic valsartan? Around $10. Sacubitril alone? Still expensive, but not $540 more than the generic.
• Kazano (alogliptin/metformin): Combo price: $425/month. Generic metformin: less than $10. Even if alogliptin cost $100, you’re still overpaying by $300.
• Nexlizet (ezetimibe/bempedoic acid): Ezetimibe has been generic for years. Bempedoic acid is new. The combo costs $12 a day in the U.S. That’s $360 a month. The same amount of ezetimibe alone? $5. You’re paying $355 extra for a new drug - and getting an old one for free.

These aren’t rare cases. They’re the norm. And they’re not just hurting Medicare. They’re hitting private insurers, employers, and patients with high deductibles.

Why Doctors Still Prescribe Them

You might wonder: if the savings are so obvious, why aren’t doctors just prescribing separate generics?

One reason: convenience. Patients with multiple conditions often take 5-10 pills a day. A combo reduces that to 3 or 4. Studies show adherence improves by 15-20% when pill burden is lower. That matters. Missed doses lead to hospitalizations - which cost far more than the drug difference.

Another reason: inertia. Many doctors aren’t aware of the cost gap. Pharmacy systems often default to the combo because it’s listed first in the formulary. And patients? They’re told, “This is simpler.” They don’t ask about price.

Pharmaceutical reps also push combos harder. They get bigger commissions on new, branded products - even when cheaper alternatives exist.

Who’s Winning and Who’s Losing

The winners? Drug manufacturers. Companies like Novartis, Merck, and Bristol Myers Squibb made billions from these combos. Their profits rely on the fact that most patients don’t know they can save money by asking for generics.

The losers? Patients. Medicare. Medicaid. Employers. Taxpayers. In 2021, combo drugs made up just 2.1% of prescriptions but accounted for 8.3% of Medicare Part D spending. That’s a massive imbalance.

Even worse, Medicare pays 22-33% more for the same brand-name drugs than the VA does. So if you’re on Medicare, you’re paying more than a veteran with the same condition.

What’s Being Done About It

There’s growing pressure to fix this. The Inflation Reduction Act of 2022 gave Medicare the power to negotiate drug prices - including combos. That’s a big deal. For the first time, the government can step in and say, “This combo costs too much.”

The FDA is also speeding up approval of generic versions of individual components. More generics = more competition = lower prices. And pharmacy benefit managers (PBMs) are starting to block combos from formularies unless there’s a clear clinical reason.

Some insurers now require prior authorization for combos. Others have “preferred generic” policies - meaning if you can get the same drugs as separate generics, you’ll pay less. University of Michigan Health System found that switching patients from combos to generics saved an average of $1,200 per patient per year.

Novartis even launched an “Entresto Access Program” offering the combo for $10 a month to Medicare patients. Sounds generous? It is - but it’s still $9 more than generic valsartan alone. And it doesn’t fix the system.

What You Can Do

If you’re on a combo drug, here’s what to ask your doctor or pharmacist:

1. Are both components available as generics?
2. What’s the total cost if I buy them separately?
3. Is there a clinical reason I need the combo - or is this just convenience?
4. Can I try the generics first and see how I feel?

Many patients are surprised to learn they can split the combo. Your pharmacist can often fill two separate generics in the same blister pack - same convenience, way lower price.

And if your insurance denies coverage for the combo? Appeal. Cite the Medicare study. Show them the numbers. You’re not being difficult - you’re being smart.

The Bigger Picture

This isn’t just about pills. It’s about how our healthcare system lets companies charge inflated prices under the guise of innovation. Combo drugs are a perfect example: marketed as progress, but often just a way to extend profits.

The good news? We’re starting to see change. More people are asking questions. More doctors are checking prices. More insurers are pushing back.

If you’re paying hundreds a month for a combo pill - you’re not alone. But you don’t have to keep paying it.

Frequently Asked Questions