Costs and Coverage of New Hepatitis C Drugs

Potential drug candidates will need to consider the drugs’ steep price

By David Linney | 10.24.2011

Originally Published October 2011

The bleeding disorders community welcomed the news in May that the US Food and Drug Administration (FDA) had approved two new drugs to treat hepatitis C. Boceprevir (Victrelis™) and telaprevir (Incivek™) are protease inhibitors used with pegylated interferon and ribavirin to help patients with hepatitis C clear the virus.

As these drugs come to market, the community will begin to learn how people with hemophilia and hepatitis C—some of whom also have HIV—will respond to them. Whether either of the drugs is a treatment option for a particular patient should be considered in consultation with a liver specialist and a hematologist.

One issue potential candidates will need to consider is the drugs’ price, which will be added to the already steep cost of interferon and  ribavirin.

The Victrelis regimen involves taking four tablets three times a day for either 24 or 48 weeks, depending on a person’s response. The treatment begins with pegylated interferon and ribavirin for the first four weeks, then Victrelis is added. The weekly cost of Victrelis is $1,100, according to Specialty Pharmacy News, meaning a 24-week treatment would cost approximately $22,000; a 48-week treatment would cost $48,400.

The Incivek regimen involves taking two tablets three times a day for 12 weeks at a cost of $49,200. After 12 weeks, patients stop taking Incivek and continue the regimen with pegylated interferon and ribavirin. Depending on the response to the drug, the treatment regimen is either 24 or 48 weeks.
The high cost of interferon and ribavirin treatment—approximately $30,000 for 48 weeks—would need to be added to either treatment. (Ribavirin is a pill available under various brand names. Pegylated interferon is sold under several brand names and is injected, typically by the patient.) Future hepatitis C drugs are expected to be even more expensive.

The increased costs of treating side effects of the new drugs must also be considered. The most common side effects of Victrelis are fatigue, low red blood cell count, nausea and headache. The most common side effects of Incivek are rash, low red blood cell count, nausea, fatigue, pain, headache, diarrhea, itching (pruritus), and anal or rectal irritation. The rash can sometimes be so severe that patients must stop treatment.

Insurance Coverage

Most insurance plans will provide coverage for any of the four drugs used in hepatitis C treatment. Coverage will vary.

Insurance plans will typically require preauthorization for coverage of any of the four drugs as part of an overall treatment plan. They may also have monitoring and adherence requirements.

Be Proactive

If your medical team agrees Victrelis or Incivek may be an option for you, be sure you know what your costs could be. Verify the details of your insurance coverage and out-of-pocket costs, as well as any preauthorization or monitoring and adherence requirements.

It is hoped that these new drugs will usher in a new era of more successful hepatitis C treatment.

Different Plans, Different Costs

For patients whose insurance coverage includes a drug plan, hepatitis C drugs are typically covered. Actual coverage will depend on the numbered tier, or classification, under which each drug falls. Hepatitis C drugs may be covered under brand, nonpreferred brand or specialty pharmacy drugs. The higher the numbered tier, the higher the copayment. Drug plans usually have copayments (or, less commonly, co-insurance) for each drug tier.

If insurance does not include a drug plan, coverage is usually through the health plan, which is often subject to a deductible, co-insurance and an annual co-insurance limit.

For people with no drug plan, the health plan will usually cover both hepatitis C drugs and homecare factor products. This will often result in cost savings, as most plans have a single deductible and a single annual co-insurance dollar limit.

For people with a drug plan that covers hepatitis C drugs and a health plan, coverage is separate. They will generally have two sets of out-of-pocket expenses—one for the drug plan and the other for the health plan.

People whose drug plan covers both hepatitis C drugs and factor products will commonly have coverage and out-of-pocket expenses applied per prescription order.

Medicaid

Under Medicaid, hepatitis C drugs and factor products are typically covered as a drug benefit. Some individuals may be subject to a small copayment.

Medicare

Hepatitis C drugs are covered under Medicare Part D, along with other drugs. Part D out-of-pocket costs for 2011 include a $310 deductible; 25% of the next $2,530 of drug costs ($633); the next $3,610; and approximately 5% of drug costs. This means out-of-pocket costs for hepatitis C drugs could be expensive, exceeding $8,500.