Express Scripts vs Caremark: The Battle for Hepatitis C Coverage

Roni Shye
Roni Shye, PharmD BCGP BCACP, is a licensed pharmacist in the states of Florida, Ohio, and Pennsylvania.
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In the past year, the realm of hepatitis C treatment has been flourishing. Several new medications have received FDA approval and have changed the way we treat this often silent disease.

With the introduction of new first line treatments, slowly but surely, we will begin to see the discontinuation of many older hepatitis C treatments. Incivek was pulled by its manufacturer, Vertex Pharmaceuticals, back in October. Alternative treatments are now available, which ultimately lead to a decrease in demand for Incivek.

The availability of new oral hepatitis C treatments will not only help improve disease cure rates but also positively impact patient compliance and the incidence of side effects.

There have been four new oral hepatitis C medications approved in the past year or so, and they’ve proven to be very effective:

However, with new and improved medications also comes a hefty price tag. A 12-week course of one of the newer Hepatitis C medications can cost anywhere from $83,300 to $95,500 which is equivalent to around $1,000 per pill.

In light of that extremely high cost, two of the largest pharmacy benefits managers, Express Scripts and CVS Caremark, have taken their stance on which new hepatitis C medications they will cover for their subscribers. (Pharmacy benefits managers—PBMs—administer the prescription portion of your insurance.)

Express Scripts has negotiated a discount with manufacturer AbbVie to cover their Viekira Pak exclusively as of January 1, 2015. There will be some exceptions—if you’ve already started treatment on Sovaldi or Harvoni, you’ll still be covered, and since Viekira Pak only treats genotype 1 hepatitis C, Sovaldi will still be available for patients with other genotypes. You can find more information in the Express Scripts press release here.

CVS Caremark, on the other hand, will exclusively cover both Sovaldi and Harvoni from Gilead Sciences. They have potentially negotiated a discount with the manufacturer as well, but claim that the decision was based on a variety of factors including how long the treatment regimens last, and how many patients they can treat. For more information on the CVS Caremark decision, refer to these articles.

A smaller PBM, Prime Therapeutics, also recently announced their hepatitis C coverage for 2015. They will cover treatments from both AbbVie and Gilead Sciences for their subscribers; Prime Therapeutics will include both Viekira Pak (AbbVie) and Harvoni (Gilead Sciences) on their formulary. Take a look at the press release from Prime Therapeutics here for more information.

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