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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
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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
Does Patient Cost Sharing for HCV Drugs Make Sense?
Darius N. Lakdawalla, PhD; Mark T. Linthicum, MPP; and Jacqueline Vanderpuye-Orgle, PhD
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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
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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
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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
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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
Member cost negatively affects initial medication adherence and manufacturer coupons can decrease member share by up to 98%.
The logistic regression model results in Table 2 demonstrate the association between member cost and abandonment starting at $2500 to <$5000 (odds ratio [OR], 1.9; 95% CI, 1.01-3.43; P = .0393). There is a trend toward abandonment at lower member cost; however, results were not significant in the adjusted model. The $5000 to <$10,000 and $10,000 or more member cost groups were statistically significantly associated with increased sofosbuvir abandonment (OR, 1.7; 95% CI, 1.03-2.79; and OR, 21.2; 95% CI, 13.6-33.5, respectively). Members with higher total drug costs (health insurer plus member amount) for non-sofosbuvir pharmacy claims in 2014 had a lower odds of sofosbuvir abandonment (OR, 0.24; 95% CI, 0.16-0.36 for total drug cost [health insurer plus member amount] for non-sofosbuvir pharmacy claims of $4500 to <$12,000; OR, 0.25; 95% CI, 0.18-0.36 for $12,000 to <$68,000; and OR, 0.13; 95% CI, 0.08-0.22 for more than $68,000). Similarly, compared with members with low pharmacy risk group scores, those with higher scores had lower odds of abandoning sofosbuvir therapy (OR, 0.41; 95% CI, 0.27-0.6, for pharmacy risk group score 6 or higher). The logistic regression model had a C statistic of 0.816, suggesting good concordance with sofosbuvir abandonment and member cost. The sensitivity analysis using abandonment rates at 180 days yielded similar results (data not shown).
There were 1123 (28.1%) of 3991 members using the specialty pharmacy for their index sofosbuvir prescription and 585 (52.1%) of 1123 members had evidence of a coupon applied to their index claim. The average member sofosbuvir index claim cost share was $1349 before a coupon was applied and only $28 after. Median member cost share decreased from $150 before the coupon to $4 after the coupon. Overall, coupons offset the member amount paid by 98%. Coupons amounted to $771,593 of the $787,860 total member cost. Table 3 reviews index sofosbuvir amounts before and after a coupon was applied. None of the 585 members with a coupon abandoned their index sofosbuvir claim.
These findings have 3 main implications. First, our results show a wide array of members’ insurer-required cost-share amounts for a sofosbuvir initial prescription. These member cost shares range from less than $250 for two-thirds of members to $10,000 or more for 5% of members. Second, among the subset of members with a known manufacturer coupon applied, the coupon paid down the member cost share by an average of $1321, meaning that coupons paid 98% of insurer-required member costs, leaving an actual member mean cost share of $28. These sofosbuvir coupon data demonstrate that when a coupon was applied, the member paid a nominal amount for their initial sofosbuvir prescription. Lastly, using the insurer-required member cost share and sofosbuvir prescription abandonment rates, the data revealed 3 levels of associated abandonment: <$250 at 4.1%, $250 to <$10,000 at 7.2%, and $10,000 or more at 51.7%. A statistically significant increase in sofosbuvir abandonment occurred when the cost was $2500 or more. Among the 14.7% of members with a known coupon applied, no member abandoned their initial sofosbuvir prescription. To explicitly link coupons, member cost sharing, and initial medication non-adherence (ie, abandonment), further research is needed.
Our results are consistent with other research demonstrating an association between increased member cost share and specialty drug prescription abandonment. However, in comparison to the statistically higher abandonment found at a member cost share greater than $250 seen in MS, oral oncology, and autoimmune drug categories,8-11 we did not see significant sofosbuvir abandonment until the $2500 or more level. There are several possible explanations for this difference. We did not have coupon information for members who filled their sofosbuvir prescriptions at locations other than a single specialty pharmacy. It is possible that members had and were able to apply sofosbuvir coupons at other locations. Other studies have examined adherence to medications for chronic conditions, while HCV treatment lasts 6 months or less and is curative. It is possible that the shorter treatment duration and curative capabilities of this drug motivated adherence. Members with higher cumulative drug cost (health insurer plus member amount) for non-sofosbuvir pharmacy claims in 2014 were less likely to abandon their sofosbuvir therapy, indicating that they may be less sensitive to high sofosbuvir member cost sharing due to the curative value. In addition, sofosbuvir abandonment could have been affected by what a member anticipates they will pay for drugs in the future as a result of reaching their pharmacy benefit–defined maximum annual cumulative out-of-pocket cost.
Although these abandonment findings are severely limited by the lack of coupon-adjusted member cost share, they are directionally informative and the insurer-required member cost share is an amount told to the member by the pharmacist at the time the prescription is filled. In addition, a member’s knowledge of a coupon is dependent on his or her own research or on the pharmacy informing them.

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