Transition to Commercial Supply of COVID-19 Oral Anti-virals

Impact: Relevant to all lines of business

On Nov. 1, 2023, manufacturers of oral anti-viral medications for COVID-19 will begin to distribute these NDA-labeled products into traditional commercial channels. Prime/Magellan Rx expects to begin seeing claims for these products on Nov. 1

As commercialized products will be reimbursed through the negotiated retail network contracts, out of network (OON) pharmacies may experience rejects depending on the member’s out of network benefits.    

We are working closely with manufacturers, per federal instruction, as they communicate more specifics on the logistics of this commercialization. Below is what we know as of Oct. 31, 2023. 

Patient Assistance Programs (PAPs) 

The Centers for Medicare & Medicaid Services (CMS) confirmed that PAP will be available for all Medicare members who have prescription benefits. The programs differ by product and are offered by the manufacturers. 

Paxlovid will be leveraging the Pfizer PAP. Health care providers or pharmacies that have signed-up may enroll patients when it is identified that the member needs the product.   

• Health plans should not see billing for these claims for enrolled members once the program has opened  
• Program not opened until December 2023 

Through Dec. 31, 2024, eligible uninsured individuals, Medicare and Medicaid members can access Paxlovid with no out-of-pocket costs through Pfizer’s PAP. Enrollment is required. 

There are no known coupons for commercial members at this time. However, we expect commercial members will continue to be able to access Paxlovid as coverage is established over the next few months. Pfizer has also stated that a copay savings program will be established for those with private insurance, which will be independent of the PAP. 

Lagevrio will be leveraging the MERCK PAP in which health care providers enroll the member when seen and have the product delivered to the patient. 

• Health plans could see billing for these claims 
• Pharmacists cannot prescribe 
• Program should be live mid-November 

We expect there to be commercial coverage for Lagevrio as well. For those who cannot afford the product, the Merck PAP will be available to assist certain patients. As federal supply is depleted, the Merck PAP intends to provide Lagevrio free of charge to eligible patients who, without assistance, could not otherwise afford the product, as determined by Merck. 

Timeline 

Over the coming weeks, manufacturers should work with CMS and other payors to make sure that such payors have the required information from the manufacturers to make payments for these therapeutics after commercial distribution begins. 

At this time, all federally acquired product should be dispensed until it is depleted or until it expires at no cost to patients. 

The final date for distributors and health care providers to order from the federal government is Nov. 10, 2023, for Lagevrio and Dec. 15, 2023, for Paxlovid. All providers should ensure that they order sufficient commercial product after November 1, ahead of the transition. 

Prime/Magellan Rx will continue to keep you informed as we learn more about the transition to commercial supply of oral anti-virals for COVID-19.

If you have questions, please reach out to your Prime/Magellan Rx client account team representative.