Post-PHE: Paxlovid and 90-day transition supply

April 19, 2023

Prime continues to prepare for the COVID-19 Public Health Emergency (PHE), which is set to expire on May 11. Below are updates to Prime’s stance on Paxlovid as it relates to Medicare, as well as further guidance from the Centers for Medicare & Medicaid Services (CMS) on the 90-day transitions supply.

Tiering for Paxlovid and Prime’s Standard formulary tiering:

  • Final tiering decisions will not be made for the Prime Standard Medicare formularies until we have pricing for this medication. Final pricing will be available once it is approved and loaded into Medispan. The Prescription Drug User Fee Act (PDUFA) date is the month of May 2023.
  • For member awareness of availability, although not currently FDA approved, Paxlovid is displayed in the nonpreferred drug tier on 2023 Prime Standard formulary publications. Note: 2024 formulary publications will not be posted until fall 2023.
  • CMS could view moving it to the specialty tier as a negative tier change, so we may decide to leave it in the nonpreferred drug tier for 2023. Note: It could be moved to the specialty tier on the 2024 formulary.
  • In the November 4, 2022 memo – Part D Coverage of Oral Antivirals for COVID-19 – CMS encourages sponsors to place at least one oral antiviral for Covid-19 products on a preferred or $0 cost-sharing tier, however this is not required by guidance. Prime does not intend to place Paxlovid in a preferred tier.
  • Regarding the 2024 formulary, pricing over the specialty cut point would provide justification to place it in the specialty tier for 2024. Any CMS challenges to specialty tiering would be expected in Stage 2, in which we could provide justification, with a final response from CMS in Stage 3. Note: Prime will perform competitive formulary analysis on the 2023 online publications. If we feel we are an outlier, we may opt to down-tier for 2024.

90-day transition supply 
After reviewing guidance and awaiting clarification from CMS, Prime has determined that plans may continue providing up to a 90-day transition supply. Guidance requires at least a month’s supply of medication, and therefore a 90-day supply meets that requirement. Further, plans have attested in their Transition Attestation to provide at least a month’s supply. These pieces of guidance are what Prime used to make this determination:

  • 42 CFR 423.120(b)(3)(iii) requires “at least an approved month’s supply of medication.”
  • CMS-4182-F, after the rules for long-term care transition day supply were amended, states “provide as a minimum…an approved month’s supply.”

Prime’s recommendation is to leave the Transition benefit at 90-day supply in place for the remainder of 2023.  A mid-year change to Transition is likely to create more confusion and a negative member experience.

If clients are still interested in reverting to the minimum month’s supply or have additional questions, please reach out to your Prime client engagement representative by May 5th.