Plans Are Likely to Treat Paxlovid Like Other Drugs if U.S. Isn’t Paying

With COVID-19 infections surging once again, the Biden administration has stepped up efforts to increase the supply of Paxlovid, the Pfizer Inc. antiviral that garnered emergency use authorization as a therapeutic treatment for the coronavirus. However, increased availability for Paxlovid might end in coming months — Congress has stalled on providing the increased COVID-19 response funding that the administration requested, and experts say health plans are likely to treat the drug like any other if the federal government isn’t picking up the tab for treatments.

The Biden administration has pushed in recent weeks to increase the availability of Paxlovid, free of charge, to COVID-19 patients. On May 26, the White House released a statement touting the rollout of more than 2,500 “test-to-treat” sites where free testing and Paxlovid courses are available, along with 40,000 locations where antivirals are available for patients. The administration also noted that it had “increased the number of people benefiting from oral antivirals in the last seven weeks, from about 27,000 prescriptions filled each week to more than 182,000 last week.”

In March, the administration asked Congress for $22.5 billion in new funding for COVID-19 testing, vaccines and therapeutics, anticipating that current supplies would be exhausted in future waves. However, Republicans have lined up against the proposal, arguing that the administration should make do with existing funding from previous pandemic aid packages. According to NPR, which in February obtained a copy of the relevant contract between the federal government and Pfizer, the U.S. purchased 10 million doses of Paxlovid.

The push for more funding is blocked by the Senate, where Democrats must overcome a 60-vote threshold on most issues and have a razor-thin margin of control. Democrats also must rely on votes from centrist members of their caucus who have begun to balk at the amount of government spending on the pandemic. A bipartisan group of senators organized a $10 billion pandemic funding counterproposal that has idled as Republicans sought to tie its passage to more restrictive immigration policy. Both measures are currently stalled, with many Republican members speaking out against any new funding at all.

“If you’re going to do anything, you’re going to need to find it…in money we’ve already appropriated for it,” Sen. Mike Braun (R-Ind.) told The Washington Post in May.

If antivirals are no longer paid for by the federal government, a possibility that is increasingly likely in coming months, experts say plans are likely to treat the drug like any other.

A Kaiser Permanente spokesperson declined to comment on the political fight over Paxlovid but told AIS Health, a division of MMIT, that presently, “if a positive COVID diagnosis is made and the physician determines Paxlovid is appropriate and prescribes it for a patient, the drug/prescription can be made available immediately for pickup at our pharmacies or shipped the same day.”

The Coronavirus Aid, Relief, and Economic Security (CARES) Act requires health plans to cover testing and vaccines for members without their paying at the point of care. In lieu of funding more purchases directly by the federal government, Congress could similarly mandate that therapeutics be paid for by plans without cost sharing. If Congress creates such a mandate for Paxlovid and other therapeutics, Ruth Liu, a principal at Avalere Health, tells AIS Health that premiums are likely to go up.

“Similar to the requirements around offering the COVID vaccine free of charge, plans would be faced with higher costs, which could impact premiums,” Liu explains. Plans “would need to update their benefits structure to ensure consumers are not charged for the new benefit should that be mandated.”

“This is not a cheap drug,” Ge Bai, Ph.D., a professor at Johns Hopkins University’s schools of public health and business, tells AIS Health. A five-day course of Paxlovid is $530. “So I think when the public health emergency ends, the plans and PBMs are going to limit usage of this drug just like they do with expensive drugs that have cheaper alternatives. So I think we will see more prior authorization or utilization control. I think patients might see some cost sharing.”

But currently, Bai points out, “plans love it [Paxlovid] because it’s paid by the government. It’s different from tests because they’re not paid by the government. Plans have no incentive to do any kind of utilization control.”

As to whether Congress will continue the present arrangement, with the federal government picking up the tab, Bai isn’t sure what will happen.

“They’re fighting right now. That’s all I can say. The Republicans are pretty adamant in their intention to end it [pandemic spending] as soon as possible. I think that depends on the dynamic on the Hill.”

Contact Bai at gbai@jhu.edu and Liu via Isabella Paladino at isabella.paladino@finnpartners.com.

Many COVID Treatments Are Sitting Unused, HHS Data Reports

By Jinghong Chen

The Biden administration has been warning for weeks that it is running low on money to purchase COVID vaccines and therapeutics, as Congress failed to approve new funding for the pandemic’s next wave. Between Dec. 17, 2021, and June 12, 2022, more than 1.3 million doses of Pfizer Inc.’s oral antiviral, Paxlovid, have been administered nationwide, accounting for 40% of the doses ordered by state and territorial health departments. Merck & Co., Inc. and Ridgeback Biotherapeutics LP’s Lagevrio (molnupiravir, MK-4482) has the lowest usage rate, with 15% of the amount ordered being used.

SOURCE: U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response.

This article and infographic were reprinted from AIS Health’s biweekly publication RADAR on Drug Benefits.

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