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The American Journal of Managed Care Special Issue: HCV
Real-World Outcomes of Ledipasvir/Sofosbuvir in Treatment-Naïve Patients With Hepatitis C
Zobair M. Younossi, MD, MPH, FACG, AGAF, FAASLD; Haesuk Park, PhD; Stuart C. Gordon, MD; John R. Ferguson; Aijaz Ahmed, MD; Douglas Dieterich, MD; and Sammy Saab, MD, MPH
Sofosbuvir Initial Therapy Abandonment and Manufacturer Coupons in a Commercially Insured Population
Taruja D. Karmarkar, MHS; Catherine I. Starner, PharmD; Yang Qiu, MS; Kirsten Tiberg, RPh; and Patrick P. Gleason, PharmD
Improving HCV Cure Rates in HIV-Coinfected Patients - A Real-World Perspective
Seetha Lakshmi, MD; Maria Alcaide, MD; Ana M. Palacio, MD, MPH; Mohammed Shaikhomer, MD; Abigail L. Alexander, MS; Genevieve Gill-Wiehl, BA; Aman Pandey, BS; Kunal Patel, BS; Dushyantha Jayaweera, MD; and Maria Del Pilar Hernandez, MD
Does Patient Cost Sharing for HCV Drugs Make Sense?
Darius N. Lakdawalla, PhD; Mark T. Linthicum, MPP; and Jacqueline Vanderpuye-Orgle, PhD
A Way Out of the Dismal Arithmetic of Hepatitis C Treatment
Jay Bhattacharya, MD, PhD, Center for Primary Care and Outcomes Research, Stanford University School of Medicine; Guest Editor-in-Chief for the HCV special issue of The American Journal of Managed
Value of Expanding HCV Screening and Treatment Policies in the United States
Mark T. Linthicum, MPP; Yuri Sanchez Gonzalez, PhD; Karen Mulligan, PhD; Gigi A. Moreno, PhD; David Dreyfus, DBA; Timothy Juday, PhD; Steven E. Marx, PharmD; Darius N. Lakdawalla, PhD; Brian R. Edlin, MD; and Ron Brookmeyer, PhD
The Wider Public Health Value of HCV Treatment Accrued by Liver Transplant Recipients
Anupam B. Jena, MD, PhD; Warren Stevens, PhD; Yuri Sanchez Gonzalez, PhD; Steven E. Marx, PharmD; Timothy Juday, PhD; Darius N. Lakdawalla, PhD; and Tomas J. Philipson, PhD
Costs and Spillover Effects of Private Insurers' Coverage of Hepatitis C Treatment
Gigi A. Moreno, PhD; Karen Mulligan, PhD; Caroline Huber, MPH; Mark T. Linthicum, MPP; David Dreyfus, DBA; Timothy Juday, PhD; Steven E. Marx, PharmD; Yuri Sanchez Gonzalez, PhD; Ron Brookmeyer, PhD; and Darius N. Lakdawalla, PhD
Currently Reading
Coverage for Hepatitis C Drugs in Medicare Part D
Jeah Kyoungrae Jung, PhD; Roger Feldman, PhD; Chelim Cheong, PhD; Ping Du, MD, PhD; and Douglas Leslie, PhD

Coverage for Hepatitis C Drugs in Medicare Part D

Jeah Kyoungrae Jung, PhD; Roger Feldman, PhD; Chelim Cheong, PhD; Ping Du, MD, PhD; and Douglas Leslie, PhD
This study analyzes the current coverage designs for hepatitis C virus drugs by Medicare Part D plans.
All Part D plans covered 2 new HCV drugs, Olysio and Sovaldi, and 98% of plans covered Harvoni (Table 2). Only 33% of MAPDs and 30% of PDPs covered Viekira Pak. Nearly every plan that covered these new drugs used prior authorization and nearly half of the plans used quantity limits. Almost all plans placed new HCV agents in a specialty tier and required coinsurance rather than co-payment. The average coinsurance rate was slightly higher among MAPDs than PDPs (31.4% vs 28.7%), but it varied more among MAPDs (20%-50%) than PDPs (25%-33%).
Cost-sharing type and amount for the new HCV drugs is fairly similar to that for the first DAAs. However, utilization management was tightened for the new drugs; for example, only 58% of MAPDs required prior authorization for Incivek.
Total spending on a single new drug for the expected therapy duration was high: $84,000 for Sovaldi; $94,500 for Harvoni; and $83,319 for Viekira Pak (Table 3). These estimates, based on 2015 WAC, appear to closely reflect total Part D spending. For example, in 2014, Part D spending on Sovaldi was $94,000 per user (the average amount paid by all Part D plans to pharmacies without incorporating manufacturers’ rebates or other price concessions).3
Harvoni and Viekira Pak can be used alone. However, Sovaldi is used with either Olysio (AASLD recommendation) or PR therapy for 12 weeks; it can also be used in combination with ribavirin for 24 weeks. Total spending for a combination of Sovaldi + Olysio was $150,360, and total spending for Sovaldi + PR therapy was $94,950.
Total spending for both single and combination new-drug therapy is significantly higher than that of the 48-week PR therapy ($43,801). Our estimate of PR therapy spending is close to what prior literature reported, considering inflation and therapy duration: a study using 2002 to 2006 commercial claims data found that 24-week spending on PR therapy was about $18,963.19
Enrollees with low-income subsidies spend between $10.80 and $1191 OOP for a full course of HCV treatment with new drugs. However, those with no subsidy need to spend much more, ranging from $6297 for Viekira Pak used alone to $10,889 for Sovaldi plus ribavirin to complete a therapy. Average OOP spending for each therapy was slightly higher in PDPs than in MAPDs; however, it varied widely among MAPDs while differing little among PDPs.
With the current Part D benefit, new HCV drug users without a subsidy reach catastrophic coverage with their first 4-week fill, regardless of their plan’s initial benefit. The mean OOP spending in catastrophic coverage, in which patients pay only 5% coinsurance, ranges (MAPDs/PDPs) from $3563/$3821 for Viekira Pak to $7966/$8152 for Sovaldi + ribavirin.
Part D plans charge relatively high coinsurance for new HCV drugs, and they require rigorous utilization management, including prior authorization and quantity limits for those drugs. Little variation in coverage exists across plans, leaving few options for beneficiaries to choose a plan with better benefits. This is likely because plans are concerned about adverse selection (attracting more and sicker HCV patients) if they were to offer more generous coverage for HCV drugs than their competitors.
The analysis indicated that the current Part D cost-sharing subsidies help mitigate financial hardship for low-income patients who need expensive new drugs; however, total OOP spending for patients with no subsidy to complete a new HCV therapy is significant, reaching almost $10,000. This suggests that the presence of catastrophic coverage, which was designed as a stop-loss in Part D, and the recent in-gap discount for brand name drugs, do not offer significant financial protection to Part D enrollees requiring high-price drugs.

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