Antiviral Coverage for H1N1 (Swine)

[Nochmar]

How has the current situation with the impending return of Swine flu during Seasonal Flu season affected your coverage of Tamiflu and Relenza?

Do you have any restrictions on the coverage of these meds?
e.g. treatment vs. chemoprophylaxis, quantity limits, etc.

Have you created a stockpile of these meds already or are you counting on the availability of a national stockpile? How did you decide how much to stockpile?

Are you using CDC criteria for use as your standard or have you created your own?

[diana.papshev]

Anonymous response from one of our members:

"We will cover these in accordance with Medicare rules – if it is treated like influenza, it will be covered under Part B; otherwise, it will be covered under Part D. Most likely, it will be Part B. Hopefully, CMS will publish guidelines on this soon. Since my plan is all Medicare, we wait until they make a decision."

[diana.papshev]

Analysis of 8 plans' commercial formulary policies shows that prior authorization is not typically used with these agents (none of the 8 plans require PA for Tamiflu or Relenza). All plans enforce quantity limits but there are significant variations in the limit thresholds set by the plans. Some quantity limits apply only to treatment while others apply to treatment and prevention:

Aetna:

- Tamiflu 75 mg - 20 caps per 12 months
- Relenza - 2 cartons per 12 months
* Also see the link above on the comment on stockpiling

BlueCross BlueShield of AL:

- Tamiflu 75 mg - 10 caps per 1 month
- Relenza - 1 carton per 1 month

Cigna:

- Tamiflu 75 mg - QL threshold not provided
- Relenza - QL threshold not provided

Highmark Blue Shield

- Tamiflu 75 mg - 10 caps per RX
- Relenza - 1 carton per RX

Humana

- Tamiflu 75 mg - 56 caps per 12 months
- Relenza - QL threshold not provided

RegenceRx

- Tamiflu 75 mg - 20 caps per 6 months
- Relenza - 2 cartons per 6 months

United

- Tamiflu 75 mg - QL threshold not provided
- Relenza - QL threshold not provided

Wellpoint

- Tamiflu 75 mg - 42 caps per RX
- Relenza - 1 carton per RX

Also, see related discussion on this topic from April 2009

[participant1]

We allow 2 treatments in 1 year and no prior auth.

For stockpiling, I heard that Roche has a program for employers to reserve a guaranteed supply of Tamiflu for 15 thousand dollars per year - unbelievable!

[diana.papshev]

Corporate Pandemic Stockpiling of Tamiflu Program was announced by Roche in June of 2008

[stockrabbit]

we are seeing a lot of abuse in the use of the antivirals..primarily from the ERs... we are a local medicaid plan, so we are a bit more involved in the PA process. we are going to allow rphs to use their judgment to dispense without our approval (and ask for PA for reimbursement)...the criteria is based on the latest WHO guideline and it is distributed to our physicians and pharmacists. i know there is a lot of discussion around the use of antivirals..but i think the key is appropriate use based on clinical symptoms... the physicians just need to be updated on the latest development...

here is what we have for now as a quick reference guide:

The following is the latest information regarding the H1N1 Antiviral Treatment guidance from WHO on August 20, 2009. http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/index.html

Google Keyword: WHO H1N1

1. 12 countries have reported cases of resistance to Tamiflu (oseltamivir). Physicians should use the antiviral drugs appropriately according to the guidance.
2. The World Health Organization advised doctors that even those who are sickened with swine flu do not need to be given Tamiflu or Relenza if they are only mildly or moderately sick and are not in a high-risk group (such as children under 5, pregnant women and those with an underlying health condition such as asthma, diabetes, or those with reduced immunity such as people with HIV).
3. Oseltamivir, when properly prescribed, can significantly reduce the risk of pneumonia (a leading cause of death for both pandemic and seasonal influenza) and the need for hospitalization). The drug treatment should be used for patients who initially present with severe illness or whose condition begins to deteriorate.



for pharmacy:
Tamiflu will be approved if the following criteria are met: (during non-business hours, pharmacists may dispense Tamiflu if the Member meets one of these criteria):

1. Members with H1N1 clinical presentation AND

a. children under 5
b. pregnant women
c. with an underlying health condition such as asthma, diabetes, or those with reduced immunity such as people with HIV)

2. Members with Severe or Progressive H1N1 clinical presentation
Signs and Symptoms of Severe and Progressive disease include, but not limited to:
• Shortness of breath, dyspnoea, tachypnea, hypoxia and /or radiological signs of lower respiratory tract disease (pneumonia)
• Exacerbation of underlying chronic disease
• Symptoms and signs suggesting oxygen impairment or cardiopulmonary insufficiency
• Altered mental status, unconscious, drowsiness, or difficult to awaken, seizures, confusion, severe weakness or paralysis
• Severe dehydration