The New COVID-19 Antivirals: What Employers Need to Know
Two new COVID-19 antiviral medications – the first oral prescription-only treatments– have shown success in reducing the risk of hospitalization and death. The drugs mark a significant milestone in our ability to manage the virus but, as with most things in the pandemic, there is no roadmap to guide employer health plan sponsors as they consider how to cover these medications.
The Federal government is covering the drug ingredient cost during the Emergency Use Authorization (EUA) periods for these medications. Plans are not required to cover these medications through their pharmacy benefit, but if they choose to do so they will be responsible for the prescription dispensing fee and any additional fees from the PBM/carrier (e.g., administrative fees). While each PBM/carrier has adopted a slightly different coverage approach, we recommend plans cover these medications through the pharmacy benefit to provide access to the therapy and reduce potential hospitalizations and deaths among their high-risk members.
Introducing Paxlovid and Molnupiravir
Paxlovid (made by Pfizer) received an EUA for the treatment of mild-to-moderate COVID-19 in persons 12 years of age or older who are at high risk for progression to severe COVID-19hi Paxlovid should be initiated as soon as possible after diagnosis and within five days of symptom onset. Plaxovid has significant drug interactions with several maintenance medications, and dosing of these medications may need to be adjusted.
Molnupiravir (made by Merck/Ridgeback Biotherapeutics) received an EUA for the treatment of mild-to-moderate COVID-19 in adults 18 years and older (not recommended for use during pregnancy) who are at high risk for progression to severe COVID-19, and for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate. Molnupiravir should be initiated as soon as possible after diagnosis of COVID-19 and within five days of symptom onset.
Employer considerations
As health plan sponsors work with their pharmacy vendor to ensure appropriate coverage, here are a few things to consider:
- Costs on the pharmacy side will likely increase due to dispensing and administrative fees. However, there may be savings through the medical benefit due to reduced hospitalizations and improved health outcomes. PBM and carrier dispensing fees vary, but the highest is approximately $11 per prescription. Some, but not all, PBMs/carriers are charging administrative fees to cover IT updates, the creation of utilization management strategies and putting safety procedures in place. It’s worth reviewing these fees since they aren’t universal across PBMs/carriers.
- Quantity limits appear standard for the PBMs/carriers and are clinically reasonable in our opinion. We are seeing differences in the allowed frequency of new prescription doses – for example, every 30 days vs. 180 days. Override criteria should be available if members need access to these antivirals more frequently than the limit allows.
- System edits should be in place to ensure safety. As mentioned above, Paxlovid is available for those 12 years of age and older while Molnupiravir is only authorized for individuals 18 years or older. Ask your PBM/carrier what edits they have implemented in line with the EUA prescribing guidance and concurrent drug utilization rules to stop dispensing if a member has a drug or disease state interaction.
- Guarantees and rebates are not available for these medications. Plans should revisit this position when the government stops paying for the ingredient costs.
- Formulary placement should be considered once these medications receive FDA approval. PBMs/carriers may be able to require a preferred product approach.
With COVID-19 cases still spiking across the US, plans sponsors should connect with their PBMs/carriers as soon as possible regarding coverage of these new medications.