1. Accessing HCV Medication Through Insurance
  2. Hepatitis C Treatment Update
  3. Treament of Hepatitis C 2019
  4. Examining the Costs of Treating Hepatitis C and the Future of Treatment
  5. Liver Disorders: Hepatitis C | Sammy Saab, MD, MPH, UCLA | UCLA Digestive Diseases
  6. How Prescription Drug Coverage Works: Formulary Tiers, PBM, Rebates, Spread-Pricing Explained
  7. Hepatitis C: Saving 90%+ Through Medical Tourism

Accessing HCV Medication Through Insurance

hello everyone my name is Michelle,Martin and Im a clinical pharmacist at,the University of Illinois at Chicago I,work at the University of Illinois,Hospital and Health Sciences system,liver clinic I have been working with,hepatitis C patients since 2009 so Im,excited to talk to you today about the,challenge of obtaining hepatitis C virus,medication approval my objectives for,today are to discuss how to tie to C,virus treatment goals and costs as well,as review some sample Medicaid and,Medicaid managed care requirements for,hepatitis C virus medication coverage,and also will list some patient,assistance programs that can assist you,first I wanted to do a little bit of,background on hepatitis C virus just to,bring everyone up to speed,hepatitis C virus is the most common,blood-borne infection in the United,States,its nearly four to five times as,prevalent as HIV is and hepatitis C,virus is leading known cause for liver,transplantation its also the main cause,of liver related death and stage liver,disease as well as hepatocellular,carcinoma there are many different,hepatitis C virus genotypes actually six,of them that have treatment,recommendations and there are many,different subtypes denoted by small,letter A B etc theres actually no,current vaccine available they are,certainly working on this but we dont,have a vaccine for hepatitis C virus at,this point in time but we do have,effective treatment as you can see by,the table here we have many patients in,the world that are affected by hepatitis,C virus its estimated that about 177,million people have hepatitis C virus,worldwide and the global death rate is,estimated at nearly 400,000 people per,year in the United States its estimated,that we have between two and a half and,four point seven million patients with,hepatitis C virus and of course the,death rate the United States is actually,climbing so we have nearly 20,000,patients that die each year from,hepatitis C so its our goal to treat,more people to help cure their hepatitis,C,prevent these morbidity and mortality z,that we see with hepatitis C virus so,what is the goal of our hepatitis C,virus treatment we want to achieve a,cure a cure is denoted by a sustained,viral logic response or SVR and this SVR,means that no virus was detected in the,blood at 12 weeks after the completion,of hepatitis C virus treatment so its,important to get your blood checked,during treatment and at the end of,treatment as well as 12 weeks after,treatment to maintain that we have a,cure just to highlight that the goal for,hepatitis C virus is shared by providers,patients and insurers,we all want to make sure that we cure,the patients who are treated for,hepatitis C virus so lets talk a little,bit about the progression of hepatitis C,virus here we note that on the bottom of,the screen we have the approximate time,in years although this progression of,hepatitis E virus differs among patients,and the time of their infection and,other cofactors so starting off with,acute infection some patients will,display symptoms or signs of acute,infection including jaundice malaise,some nausea and just general symptoms,that may be dismissed about one in six,to one and four people actually can,spontaneously clear the virus and not,develop chronic hepatitis C virus,however the majority of people actually,do go on to develop chronic infection,they can then go on to develop mild,moderate or severe hepatitis and of,those patients about one in five will go,on to develop cirrhosis or the most,advanced scarring of liver from there,some of those patients will decompensate,being that their liver will no longer be,able to do its job well and from there,we move on to end-stage liver disease,and the need for transplantation other,patients with cirrhosis will go on to,develop hepatocellular carcinoma so,thats why its so important that we,treat hepatitis C virus ideally before,patients develop cirrhosis that we can,prevent these other things from,occurring we also want to make sure that,were screening our patients with,advanced fibrosis and cirrhosis,to make sure that theyre not developing,hepatocellular carcinoma so now well,move into the hepatitis C virus,treatment evolution on the y-axis along,the left hand side you can see the cure,rate or the SVR rate thats associated,with specific regimens for hepatitis C,treatment along the x-axis or the bottom,you can see the different treatment,regimens and when they were first used,and then you can see what their level of,cure or cure rate was you can see that,back in the 1990s that the cure rate was,very low with treatment treatment had a,lot of side effects and a lot of,patients did not enjoy the course of,treatment because it was much more,difficult with a lot of side effects,that they this slide goes over the,hepatitis C virus treatment evolution on,the y-axis you can see the SVR H or the,cure rate along the x axis at the bottom,you can see the different medications,and when they were approved for use for,hepatitis C virus treatment you can see,since the 1990s the cure rates has,improved drastically for the medications,that we had in 2011 we had our first,direct-acting antiviral agents approved,that were added on to treatment with,pegylated interferon and ribavirin these,earlier treatments for hepatitis C virus,had a lot of side effects in patients,health usually a lot of complaints,during the course of treatment starting,in 2013 we had the approval of all oral,treatment for hepatitis C virus so as,you can see weve had several different,medications approved and now we have,eight different regimens for patients,who have genotype one so there are a lot,of different options as far as the,medications that we can use and as you,can see by the SVR rates these agents,are highly effective so patients enjoy,fewer side-effects and most patients,achieve a cure the problem of course is,how do we pay for that cure so there are,a few different ways that we could pay,for hepatitis C virus treatment of,course the first would be paying cash,for the treatment I have had very few,patients that have actually been able to,do this due to the high cost of,treatment,the most common way to pay for hepatitis,C virus is through insurance and,certainly we do have some patient,assistance programs that can help either,with co-payments or to cover the entire,cost of the medications in some specific,instances so this slide just goes over,the wholesale acquisition cost or the,advertised price of the medications for,hepatitis C virus I bet youre all,thinking wow these medications are super,expensive and it is true,thats why hepatitis C virus treatment,has been such a challenge for most,people to get medication approved,through their insurances so you can see,on the top listing on the left-hand side,we see all the different medications,that are available and you can see on,the in the middle column we have the,cost for eight weeks because because we,have two Frenchmans that are actually,available for eight week treatment arms,in the middle column we have the cost,for twelve weeks and most agents are,able to be used for twelve weeks its,much less common now that we would need,to treat a patient for 24 weeks as you,can see those medications and regimens,are much more expensive when theyre,doubled or tripled in length for cost so,how do we weigh these costs of course,the costs of genotype one treatment can,be as little as twenty six thousand four,hundred dollars as that wholesale,acquisition cost up to ninety four,thousand five hundred dollars for the,wholesale acquisition cost of a,combination regimen versus the costs of,a liver transplantation if a patient is,unable to get treatment and then has,progression of their liver disease such,so that they would actually decompensate,and need a liver transplantation the,cost is extremely high so it makes sense,to treat people early so that they dont,decompensate and need a liver transplant,I think its important to go over that,insurance basics fo

Hepatitis C Treatment Update

[Music],welcome this is brian wood medical,director for the mountain west aetc,project echo telehealth program,each of our weekly sessions starts with,a short talk focused on issues relevant,to hiv clinical medicine,the following talk was recorded live,here at university of washington we will,now take you to this weeks talk,[Music],great thanks hillary and welcome,everyone so this is gonna be a two-part,series im gonna cover some of the,clinical aspects of hepatitis c some of,maybe some new things you may not have,seen and then next week david hatchy is,going to talk about some of the common,drug drug interactions,so if you have questions like that i,mean you cant wait maybe ill call on,david in that area so just a little bit,of my disclosures here none of them are,relevant to todays talk but i tend to,over disclose,so what i wanted to do is briefly just,give a quick epidemiology update because,that has changed in the last couple of,years and then move on to some of the,new practice guidelines from the double,asld and idsa hcv guidelines,talk about what to do when people,have interruptions in their hcv therapy,and then wrap up with this question,about pregnancy and acv therapy,so just a little bit of the background,about hep c,and this is data from the cdc is that,were seeing more cases of hepatitis c,both in acute hepsy and chronic hep c,so this first study was reporting over 3,000 cases of acute hep c and i think,thats probably a massive underestimate,because it can often be occult and not,recognized so we think that there are,more likely to be somewhere around 50,000,new cases of hepatitis c every year,and this is a three-fold increase over,roughly the last 10 years from 0.3 in,2009 now to around 1.2 per hundred,thousand,and you can kind of see that its not,all age groups that are being affected,this is part of the whole opioid,epidemic so,younger folks are be more affected than,other age groups so this biggest line,here,is the 20 to 29 year old age group and,then followed pretty closely by the 30,to 39 year olds,the one thing i will point out is there,still is some increase in the other age,groups and i think that is also a,reflection of injection drug use,particularly with opioids,so this next slide shows where we are,with the chronic hepatitis c and if i,were to show this slide 10 years ago it,would have been a kind of a classic just,peak in the baby boomers so those folks,who were born between 1945 and 1965.,so it was kind of like that one humped,camel now were were looking at a,two-humped camel and what you can see is,that the,younger folks so,folks between approximately 24,to mid 30s,represent the most number of cases,theyre now surpassing the baby boomer,cohort,and just a little bit about how its,impacting mortality is it was the number,11 cause of death in 2017 which is i,think the most recent,reliable national data that we have,representing approximately 17 000,deaths and this death rate is around,four per hundred thousand but its often,listed as an underlying cause of death,and deaths in which theres not the,primary cause so 29 percent listed hcv,is underlying cause of death,and in those cases where theres like a,liver-related cause of death its its,like hcc,alcoholic cirrhosis or some other kind,of neopos in the liver so we think that,this is probably contributing there the,good news is this is declining probably,reflects some of the newer antivirals,that have started coming on board in the,mid 2010s,if you look at which states are most,affected by hcv mortality i just want to,draw your attention to the pacific,northwest where both washington oregon,have some of the highest age-adjusted,mortality and then also the southwest so,new mexico texas and oklahoma and a,little bit here in d.c,so this is still an issue even with some,great antivirals out there were still,not out of the woods,so i want to turn from the epidemiology,now start talking about some of the,changes the asld idsa guidelines and,just a disclosure that i sit on that,committee and dont speak for them today,but i just want to let you know some of,the changes that weve made,and overall i think there was just a,push to make the treatment guidelines,simpler and streamlined theres a bunch,of medications that were just theyre,not longer being marketed or rarely used,so weve tried to take some of those out,so theres updates on how to order your,workup labs how to monitor patients,while theyre on therapy and then what,what to do with vosavi or softwall box,failures,so the initial labs and work up are,listed here in the green box,and just a kind of a simple thing you,should be doing and usually this is a,couple tubes of blood get a cbc,a liver function test nine our,creatinine so i think theyll probably,give you,three tubes of blood,and from that you can calculate both,the asc to platelet ratio or opry,or something called the fib four so the,fib4,is very similar to the apparatus using,the ast and platelets but it does take,into account the age,and so ive seen a couple people,have maybe a really low opry or a very,high opportunity but then when you do,the fib 4 it gives you a little bit,different information so if i had to,choose between those two,i would use the fib for and this,information is available on the acv,online website if you wanted to you know,bookmark that and be able to get to it,quickly in my office where i have fiber,scan available almost everyones getting,that otherwise known as transient,elastography,it takes about five or ten minutes just,a,sound wave that my staff is trained to,do and and i do it as well,but it is is very accurate about ninety,percent sensitive for picking up severe,fibrosis and i like to use both the fib,four,and the transcendental osteography,because theyre a little bit different,test,if you didnt have fiber skin i think,the next best option would be fiber,short thats a blood test it costs,around 250,i will just warn you that in my,experience for the last like five years,its probably the least accurate ive,seen it overestimate and ive seen it,underestimate,so if you get something wacky its,usually the fiber shirt thats not right,and then if if you wanted a tie breaker,sometimes imaging is helpful you do not,need to get ultrasound on everyone,thats not necessarily often will add to,your costs and not really help you that,much in your work up and then liver,biopsy is still the gold standard so if,you have maybe some,tests that are contradicting themselves,say that your fit four was really low,and the fiber scan is high youre not,really sure what to do that might be a,situation where you want to get a liver,biopsy,so in addition to those tests the other,thing you want to get on your initial,workup would be urine pregnancy tests,especially if the womans of child,bearing age just want to make sure that,they do not get pregnant while on,therapy,and then kind of normal things many of,you guys already already know the hiv,status but if you dont get hiv and then,hepa and b serologies,so the asld guidelines now have a very,simplified hv therapy and this is for,someone who has no cirrhosis,you would basically your two options are,going to be,glycopreprimbrandosphere or maverick for,eight weeks,or sophosphere vapours for occlusa for,12 weeks now someone who would not,qualify for a simplified therapy as,someone whos been treated before with,the daa and failed,and then well go over cirrhosis on the,next slide anyone whos hiv or surface,antigen positive and theres some,considerations there with drug,interactions,current pregnancy,known or suspected parachute carcinoma,or prior liver transplant those tend to,be,managed more in a specialty situation so,what about cirrhosis its its basically,the same thing,and the only thing i would warn you,against is using an hcv protease,inhibitor in anyone who has childs,class b or c,so maverick does have that protease,inhibitor if their childs a you can you,can treat them,i just say probably watch them a little,bit more cl

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Treament of Hepatitis C 2019

maybe a few trick as youll know is the,director use to medicine pioneering,research thanks general the Hep C,research is over its a race or its a,rap rap we have lots of other stuff but,Pepsi is over but actually before we go,to have C I just want to remind,everybody about hepatitis A epidemics,across the u.s. here New York is in,light blue but you know weve heard,these restaurants 7-eleven closed in,Nassau County and then some taco place,in Westchester and New Jersey thats,like theyre all over the place so make,sure you vaccinate everybody okay for,hepatitis A most of our patients have,not been vaccinated all our kids are,getting vaccinated now actually so you,dont have to be traveling to a tropical,isle to get hepatitis A okay Manhattan,is a top of a while you can get it at,the dirty deli downstairs so vaccinate,everybody for hepatitis A please its,embarrassing if they die of hepatitis A,okay so epidemiology so they also,everybody also said oh we cant be cured,have C now its easy no problem you can,retire well yeah not quite you know its,like we cured up over a million people,in the u.s. million million to maybe an,axial and over three million worldwide,but problem is theres more cases coming,in than there are going out because of,this new incidents at the type of C,starting somewhere around 2010 here and,its actually mostly in non-metropolitan,areas and its mostly driven by opioid,IV drug use you know the,you know the purpose at etc the Sackler,School of Medicine epidemic anyway so,and actually in New York we have we have,different slightly different numbers but,the highest incidence is in the under 30,group and the non metropolitan areas,so here were a few of the incidences,here from before 2006 by 12 it looked,like this and you can see here this is,any opioid up here theres regional,doubling three out of four had a history,of opioid use so you all know that story,about oxycontin they dont have them,meet the dead horse but the problem is,also its actually in women of,childbearing age the number of acute,cases increased about between and a half,fold and the number of past or present,cases doubled and its higher than in,the older women here so aged 15 to 44 so,its really its really sort of out of,control hepatitis C and in largely due,to the opioid epidemic and its actually,higher in women than men so for so its,about sixty three or four percent female,to male ratio and it seems to be for,some reason that younger women are way,more susceptible to becoming addicted to,opiates and younger men are not entirely,clear why that is but it can take as,little as five days still for a sprained,ankle somebody gets an oxycontin,prescription and after five days theyre,already addicted to it they cant get a,refill and they go down to the mall and,they get a bag of heroin for five bucks,which is cheaper than a latte at the,mall and which will take care of their,withdrawal symptoms and then of course,you know what about what happens from,there so this is in New York State 2005,is just the baby boomers by 2012 we,there was a baby bump here we noticed,the baby bump but by 2015 the bumps were,equal and now by 2016 2016 actually as,you can see here actually theres of the,the under 30 crowd is much more,are much more hepatitis-c than the the,baby boomers and this is actually,outside of New York City no this is,incidence yeah this is it this is,incidence but and its actually outside,of New York City it starts we rarely see,it inside the five boroughs but the,minute you cross that Nassau County Line,and across the Westchester County Line,and you cross the Hudson River it just,skyrockets actually its just out of,control so and then of course,Tatianas not just tough Duncan is not,here is she today I know shes roaming,oh right,she said West plenty of seats up front,here just like in church come in late,you gotta sit up front so the rates of,Hep C during pregnancy have also been,increasing because a majority of the,cases are in women of childbearing age,so thats thats kind of what weve been,weve been working with Tatiana and and,Rhoda Sperling from OB about treating,some of these pregnant women in the last,two months of pregnancy or last three,months of pregnancy we were sweet had,started actually to use you know harvoni,because you know the the original,genotype was genotype one but,unfortunately the new epidemic and the,indies under 30 crowd the majority is,jino three so harvoni wouldnt work so,we would need to use a clue so which we,didnt have a category are gonna need,category B in pregnancy we were going to,use a clue so it doesnt have a category,so were waiting for some PK studies and,pregnancy and pregnant women from,Australia to district to start the study,that they did finish the harvoni study,in Pittsburgh with about ten patients or,something you know treating a month C to,nine in pregnancy and it seems like it,works obviously good time to get them,into therapy when theyre pregnant for,one thing they get automatic,Medicaid if theyre bragdun if they,notice theyre not insured for another,thing women obviously are very concerned,about their health while theyre,pregnant they may not be after they give,birth or start using either drugs again,so history of hepatitis C the first pub,actually publication was in 1975 in the,annals actually was the gold edition of,the annals so they called it non-a non-b,hepatitis they still couldnt find it it,wasnt actually until 1989 that Michael,Hatton this antigen capture technique he,was able to separate the virus from the,antibody and actually make a make a,diagnostic antibody test thats the,chyron people but believe it or not,before we had the antibody test we,actually had an approval for interferon,to treat to treat abnormal liver enzymes,in patients who had presumed non-a non-b,hepatitis or chronic hepatitis on the,Rebellions so thats how blind we were,treating actually with you know with,interferon I finally figured out some of,the genome and by 93 the 3d structure,here in 96 and they had an infectious,clone constructed here in the replica,was in 1999 problem was Chiron actually,had a patent on the virus from 1989,until 1999 until somebody challenged,them and actually won the battle cant,patent a virus just like you cant,patent the human genome Hey actually but,they were actually charging all these,people money to try to do a research on,epitaxy so it slowed down the progress,quite a bit actually cause during this,this period of time HIV drugs were you,know were running rampant actually the,number of drugs because they were able,to do all those experiments nobody had,patented HIV so by 98 we had added rival,Fyren to the mixture and gotten some,better results we had and pegan and this,actually brought that well in a fair on,three million three times a week so I,some of the Duke fellows here I should,tell you this story this is drug,development 101 so how did interferon,get into the liver world so so back in,the in the late 80s at the NIH the NCIS,and thats starting at the NCI yes,thats the TV shuts actually the NCI the,National Cancer Institute thats a good,one though I like that one the NCI had,interferon they were using it for,melanoma they were using twenty million,units IV yeah seven days a week for um,for melanoma and it was obviously,terrible side effects you know just were,used to this but you know so these the,liver fellows Hoofnagle jacob nichols,sent to the fellows over go talk to the,oncology fellows see how she at what,theyre doing with this interferon and,figure out how we can try it on this,non-a non-b hepatitis because we think,its a virus so they talk to the,oncology fellows and they said well,heres two things you need to know the,side effects are terrible okay and,number number two I told Ben there or,the other night number two the nurses we,refused to administer the drug because,its so toxic and its experimental so,you have to give the drug the fellows,have to administer the drug so the the,liver fellows being sm

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Examining the Costs of Treating Hepatitis C and the Future of Treatment

with the advent of these new highly,effective therapies most of the,attention has not looked at how,effective they are how this could,prevent the future burden of disease but,on their high cost I certainly wish the,drugs cost less because Id be able to,treat more people but I have no doubts,that these regimens are cost-effective,most of the modeling data has supported,that it is cost effective and most of,the health care systems for example the,VA where they have the patient for life,has to have decided to implement therapy,because they believe it to be,cost-effective it really comes down to a,question as to whos going to bear the,cost because we have so many patients,with Hep C thats why the cost becomes,an issue We certainly have very very,expensive therapies for cancer for our,biologics are expensive for,rheumatologic diseases but because the,number of patients are so small that it,doesnt impact our overall health care,system I think when people saw four,million people with Hep C a hundred,thousand dollars a treatment regimen you,do the math the number gets really big,and people got nervous however its,important to remember we havent,identified 75% of those people were not,going to treat four million people in,the next two to three years well be,lucky if we treat the three million,people with the four million people with,Hep C in the next 10 to 20 years,I think we have to get away from the,cost of therapy and focus on the fact,that Hep C is a substantial burden of,disease in terms of quantity of life and,quality of life its been shown that,eradication of Hep C improves quality of,life improves fatigue and a lot of other,symptoms its going to prevent the extra,hepatic manifestations of hepatitis C,kidney disease the increased risk of,diabetes possibly the lower that,increased risk of lymphoma we see in our,hep c patients and has been shown that,cure of Hep C lowers both liver disease,and all-cause mortality so though I,understand the expense and we have to as,a health care system figure out a way to,pay for it I have no doubts that this is,cost-effective and its hopeful that as,we have more agents developed that with,competition the cost should come down,further and we should be able to treat,more patients but I believe that every,patient with Hep C should be a treatment,candidate and that our goal should be,eradication of hepatitis C from the,United States in as little time as we,can achieve it,when the first all oral agents came out,I think there was a lot of concern,because there were a huge warehouse as,we people called it a big group of,people whove been waiting for therapy,who all wanted to jump on board and then,there was now a sudden surge in,allocation of dollars from the insurers,to Hep C treatment I think the,difficulty is trying to get it to a,steady state so that people can,understand the costs as I said I think,this is cost effective but finding ways,to either amortize the cost bring down,the cost or more humane and effective,methods than telling a group of patients,because their diseases and serious,enough that they have to wait I cant,imagine how it feels to a person to be,told your liver disease isnt serious,enough lets wait until you develop,cirrhosis and then well treat you that,unfortunately youll carry a risk of,cancer at that point for the rest of,your life I dont think that would be,acceptable to me as a purse a patient,and its not acceptable to me for my,patients,the revolution weve had in hep-c,therapy is almost unheard of in medical,therapy its probably equivalent to when,the first antibiotics came out for,pneumonia we went from something in,which we could cure though we said forty,percent of people it was really less,than ten percent because so few patients,were eligible for therapy or willing to,take a year of interferon as an,injection with all of its side effects,for such a low response rate and then,virtually overnight we went from the,addition of the first generation,proteases to interferon which doubled,the response rate but was toxic to then,less than two years later all oral,therapies that now pushed us over ninety,percent I find that an enormously,exciting thing I think it shows that,once you put your attention to something,we can really go far where are we going,to be in five to ten years I dont see,that were going to cure Hep C in my,career I had sad that thats the case,because I think its actually doable but,we have never cured any chronic viral,disease with treatment the only viral,disease weve ever cured as smallpox we,see polio is still around measles is now,coming back and so its unfortunate that,were not still working on a Hep C,vaccine because vaccination is really,the only way that we can eradicate viral,diseases and its its requires a high,penetrance of vaccination into the,public Ive never seen a case of measles,myself my dad whos a doctor has but I,havent and younger doctors cant even,imagine it and so,and yet we have measles so I hope that,were going to have highly effective,therapies that will become lowering,costs and well have better screening,efforts that we identify more patients,but I see that in five to ten years,shorter durations may be more,individualized treatments but I wish I,could be optimistic enough to say,eradication but I dont see that even in,20 years Ill be happy and no one will,be happier than me if Im wrong on this,one but if anyone wants to take wagers,they can call me

Liver Disorders: Hepatitis C | Sammy Saab, MD, MPH, UCLA | UCLA Digestive Diseases

good morning everybody,uh great pleasure to be among all you,today talking about hepatitis c,you know and you know ive been talking,about hepatitis c for about about 15,20 years and right now were in the,midst of a major revolution,a major revolution so were the slighter,so today were talking about hepatitis c,the gift that gives on giving,so in the next 20 minutes we want to,cover,three very important aims we want to,review the,the current recommendation for screen of,hepatitis c,and as you may know this week the u.s,principal services has,changed recommendations and what they,recommend today,is that every adult between the ages of,18,and and 70 british hepatitis c at least,once their lifetime,were going to look at what are the,barriers you know,whats a barrier why are we in limiting,hepatitis c,and lastly were going to look at the,current treatment paradigm,so this is from an article published in,english medicine,and what it highlights is a public,health concern hepatitis c,viral hepatitis today kills more people,than tuberculosis kills more people,than hiv kills more people than malaria,and its a tragedy because hepatitis b,you could prevent through immunization,and hepatitis c cure the vast majority,of patients over,98 percent with pills that are safe,effective and tolerable so the next,several slides were going to highlight,you know the two most commonly,prescribed medication united states,and the take-home message is this,incredible cure rate,from this side here looking at soft,valve for 12 weeks,in people with cirrhosis and without,cirrhosis,to cure it is 98,so when we go to meetings advisor boards,consulting meetings we never argue about,the svr,we argue about why arent that two,percent being cured,you know weve become so greedy over the,past 10 years,and you see across aspects of all,genotypes,one two through six to cure is,consistently high,if you look at another agent glee p um,thinking you know three uh three tablets,once a day the cure is also,98 and the difference here,its an eight week regimen i mean could,you imagine a disease,that can cause cirrhosis,liver cancer liver failure,and you cure with pills they have no,major side effects and even with,cirrhosis,even cirrhosis people now can be true,with eight,weeks of this regimen,so we have two wonderful regimens that,cure the vast majority of fatty seed,this has has has a significant change,you know our clinics our liver,transplant,for 20 years for 20 years weve talked,about uh hepatitis c is the most common,reason for liver transplantation,the past year thats been replaced by,alcohol,and fatty liver hepatitis c is number,three,and in fact the at our transplant,committee if we discuss a patient that,needs to transfer hepatitis c,its not for liver failure its for,liver cancer,now this is a paper we published in,hepatology two years ago,we were so excited this paper got,published without,any major vision and we argue,we argue how hepatology can be,eliminated,theres no non-human reservoir we have,great therapy,treatments are cost effective theyre,not cost effective you could argue with,me theyre cost,savings the cost of drugs have come down,from,80 000 to a course to 14 to 20 000,and theres a will for this so were so,excited,and a new wave of marriage a new wave,so we were doing a great job of,screening and treating baby boomers,because historically 70 percent of all,appetites see,70 percent wrong by b boomers,you know they may have been infected in,the 50s 60s during hysterectomy,heart surgery and these people were,engaged in the healthcare system theyre,getting screened,but what has emerged is a new wave of,young,adults and these are being infected,through drug use,unlike the baby boomer culver the most,here are men,the new cohort men and women are,similarly represented,until until this week we have,no effort to screen as individuals,and unfortunately when youre 24 years,old right are you worried about your,cholesterol,or your prostate no youre not engaged,in the health care system,so they are engaged in healthcare,systems but not the way we understand it,so this is a very uh provocative paper,that was published,two years ago and basically what it,shows,is this current young generation,theyre engaged in high risk behavior,not just drugs if you go across a city,and see whos in the icu with liver,failure,who is it young adults,30 40 years of age again the same,theory about young adults being engaged,in high high risk behavior,we dont know why all these young adults,are dying of all hepatitis,but right now right now if you look in,the united states,whos dying the fastest rate from,hepatitis is,young women so we dont know why we,dont know if its because of sweet,cocktails,uber no dont laugh uber i mean right,then you drink up a martinis right,you press a button youre home in two,minutes you do all the time,professor emeritus,so in in the other and in the other and,these drug people use drugs on regular,basis theyre not part of their,theyre marginalized and and their,hepatitis c is so so,high we did a study at institution,we looked at you know thousands of,patients with hepatitis c,and the question is what are the,barriers why arent they being treated,as young people,biggest risk factor for not being,engaged in health care system not being,linked to treatment,drug use and not having uh having a home,and age age is a big problem,so if we look at across the globe,because of,people who use drugs on a regular basis,two-thirds have hepatitis c this is not,just a us problem its across the whole,globe,i was in um in dubai in september,october,at a liver conference speaking about,hepatitis c and i am and there were,doctors from egypt iraq you know etc and,i was astonished how this is a common,theme throughout the whole world,they represent a huge nidus of hepatitis,c,and along the way theyre less likely to,be diagnosed,less likely to be aware and less likely,to be treated hepatitis c,its a tragedy because if you look at,the cure rates,and people who use drugs people have a,history or recent drug use,their curious are just as high as those,individuals,in the general population,we also did a study recently published,in one of the gi journals,about treating homeless people in,downtown los angeles,the biggest challenge how to get people,to drugs right theyre homeless and i i,learned the hard way thats it there are,a lot of barriers,people lose their phones and and they,get new phones,and the cure rate among homeless people,in downtown los angeles was also very,high,the people who failed unfortunately lost,a follow-up or passed away,i know what bens thinking why would you,want to treat someone use drugs right,ben,or a homeless person why would you want,to treat them are they going to die,liver disease,are they going to get cirrhosis or liver,cancer,you treat them because its a public,health issue,the drugs are safe effective tolerable,we talk about treating a patient talk,about preventing transmission to other,individuals,in prisons also a major problem,i was on phone call with the head of,nevada prisons yesterday,um and and how theyre being sued by,inmates for notre dame hepatitis c so,theyre asking about about algorithms,to pay individuals but a large,proportion of patients,prisoners have hepatitis c and this is a,nice paper published from um from,from mass general looking at why you,want to treat prisoners,and the reason why when people leave,prisons,the risk of infected other individuals,with hepatitis c,and the cure rate across the globe its,again over 95,cure rate in prisoners,so theres a lot of benefits theres,individual benefits prevent,personal liver disease prevents ceros,and liver cancer,prevented extra paddock manifestations,that are,that are that exists irrespective of,your liver disease fibrosis stage,and the societal cure now imagine in our,lifetime we can limit hepatitis c,and this would be the first time we can,eliminate a condition a disease,not through immunization or vaccination,but t

How Prescription Drug Coverage Works: Formulary Tiers, PBM, Rebates, Spread-Pricing Explained

hello and welcome back today were going,to be discussing in this session all,things prescriptions as i mentioned in a,previous video prescriptions end up,being about,20,of all healthcare spending so we have to,understand prescriptions now,one of the most important things is the,formulator so whats a formulary so its,a list of covered medications so believe,it or not not all medications are,covered right so were going to go,through that were going to go through,the non-formulary medications that,insurance will not cover at all so what,are those,otc over-the-counter medications right,you go into the pharmacy youre like,tylenol okay you got to pay cash for,tylenol and youre like but i want my,insurance to pay for my tylenol your,insurance is not going to pay for your,timeline because its over the counter,as is true for most other,over-the-counter medications two for,cosmetic medications now this time,oftentimes they are prescriptions and,this happens a lot in with,dermatologists where some of their,prescription creams might be for like,helping with like reducing wrinkles okay,well your insurance is not going to pay,for,creams to reduce your wrinkles because,its cosmetic next up,reproductive medications so that might,be related to you know what it was,sometimes referred to as lifestyle,medications like viagra for erectile,dysfunction but also theres uh theres,pill medications that are used for uh,infertility treatment as well now it,varies by states some states require uh,fertility treatment to be covered other,states dont have requirements for them,so just know that in many cases,fertility related medications are also,uncovered non-formulary okay now the,formulary is broken up into tears as,well and those tiers determine what,copay the person pays at the pharmacy,when they get the medication now,this applies to ppo plans html plans and,pos plans this by definition does not,apply to consumer driven health plans or,cdhp plans because cdhps are not allowed,to have co-pays for office visits like,we talked about but cdhps also could not,have co-pays for prescriptions as well,so these tiers only apply to the ppo,html and positions which of course are,the majority of health plans in america,okay so tier one theyre your generic,medications they have the lowest copay,typically its around five or ten,dollars,now,that is for,particularly a 30-day supply if it is a,chronic medication or a lot of times,like for an antibiotic they only write,you for like a five-day prescription or,maybe a seven-day prescription well they,dont charge you for a quarter of a,copay because its a quarter of the,month though you still have to pay the,entire copay for a script even if its,for less than a months supply of,medications okay next tier two,is preferred brands these are brand name,medications so you know an example here,might be,like simvastatin is the generic form of,the cholesterol medication zokor so,zokor so maybe the sympathetic is the,generic that you pick 10 bucks for but,if you wanted the zokor that might be a,preferred brand and you have to pay 30,for a one month supply now,preferred means it is preferred to the,insurance company in the pbm and were,going to talk about pharmacy benefits,managers in the next video but basically,the the pbm within the insurance company,goes out and negotiates the actual,prices with the pharmaceutical company,with pfizer and mark and um,astrazeneca etc so a preferred brand is,just a brand name medication that the,insurance pbm has been able to negotiate,a better deal on with the pbm with the,pharmaceutical company so they offer it,a lower copay which then brings into,tier three which is non-preferred brand,so again these are brand name,medications in this case it might be,like crest store for high cholesterol,and so the pbm might have gotten a good,good deal on the zocor but they were not,able to negotiate a very good price on,the crest store and so like well we,dont want our patients and our members,taken as much crystal because we didnt,get as good of a deal on it so they give,it a higher copay of sixty dollars,instead of the thirty dollars now,tier four is specialty pharmacy now,especially pharmacy is special one,because it tends to be very expensive so,this is not like so typically these,branding medications might be two three,maybe even four hundred dollars a month,generics,the actual cost of the medication,shoot in some situations the generic,actually costs less than the copay so it,actually helps to look,uh and see you know you could you know,go to the website you can use like,goodrx or whatever and just see what the,cash price is i remember we got a,prescription diaper rash cream for one,of my kids their baby and it was a,dollar and eighty cents instead of the,ten dollar copay so actually not using,the insurance and just paying the cash,price was actually cheaper than the,co-pay okay but in the case of the,specialty pharmacy super expensive these,medications are thousands of dollars a,month now theyre typically for things,like injections so self-administered,injections not into your bloodstream but,just an injection under the skin and,sort of the prototypical example that is,humira which is the highest grossing,medication in the world and in america,and its used to treat rheumatoid,arthritis and crohns disease and people,give themselves a shot every two weeks,and that costs like two thousand dollars,a month okay likewise uh doesnt have to,be an injection it could be a pill so,some hiv pill medications are also like,thousands of dollars a month likewise,you act theyre actually starting to,come out with some chemotherapies that,are actually pill chemotherapies that,again are thousand dollars a month,theres even a treatment for hepatitis c,that it cures hepatitis c,but it it you take it,for a month but literally a one month,supply of that hepatitis c medication is,40 thousand dollars i mean just one pill,is over a thousand bucks one pill costs,more than a laptop computer so youre,not gonna pay a sixty dollar copay for,that so typically this the benefits are,set up such that you have twenty percent,coinsurance for specialty pharmacy tier,four and so if youre paying to if the,medication costs two thousand dollars a,month that means that your call,insurance is four hundred dollars a,month times total money youre paying,four thousand eight hundred dollars a,year for your specialty pharmacy so,these medications can be very expensive,now to the extent that you can treat,your condition with a brand or a generic,instead of a specialty pharmacy its,going to save the patient a ton of money,out of pocket and its going to save the,plan money as well and ill even give,you one example of that so first line,therapy for rheumatoid arthritis is,actually a medication called,methotrexate,that is generic its been around for,decades and the american college of,rheumatology actually recommends that,people try megaphotrexate first before,trying humira for their rheumatoid,arthritis so you can actually treat,rheumatoid arthritis with a 10 copay as,opposed to paying 400,a month,eight well i wont get into it but a lot,of,people are put on humira right away,without ever being tried on methotrexate,first so the point is is that there are,these tiers within the formulary they,have different amounts of co-pays and um,thats it for our first session on,prescriptions well be moving on to pbms,next,okay welcome back now we are going to,discuss pharmacy,benefits,managers or pbms for short now ive got,to take you back to that drawing of that,quadrilateral from the very beginning,where we have the four,actors within the healthcare system,right youve got the employer the,employee the provider in this case the,pharmacies were talking about,prescriptions and the insurance company,so the employer is providing insurance,coverage to the employees the employees,are going to the pharmacy and getting,their medications maybe they got to pay,a co-pay there okay the employer is,pay

Hepatitis C: Saving 90%+ Through Medical Tourism

good afternoon everyone welcome to our,webcast today Im medical tourism and,the cure for Hep C Im Jonathan a,delight to CEO the medical tourism,association excited to bring you this,presentation today this kind of really,cutting edge on the new medication and,treatment have amazing cure rates like,Vivaldi from Gilead and some of the,challenges a lot of cellphones employers,pbms and insurance companies are having,with a really high cough you know eighty,four thousand dollars or more for,treatment and you know my background is,from the church world and running a big,national TPA doing a lot of self funding,for large national employers and state,governments so and I was the first,person back in the early 2000s to,implement medical tourism in a,self-funded plans so Im going to really,talk about you know whats going on with,you each treatment secure rates the,impact on cost for state governments for,the employers the insurance companies,alternatives and then how medical,tourism really provides an amazing,solution and how there is a turnkey,solution right now that could have a,significant impact in saving billions of,dollars for the system so obviously you,know savala is the new miracle drug in,in hep-c treatment and you know im sure,we all have a lot of family and friends,who have it and hepatitis C treatment,costs are expected to go up by eighteen,hundred percent by 2016 just because of,savala t so massive increase but thats,because its a breakthrough therapy that,has a ninety-eight percent success rate,so it pretty much cureton so it has such,a big impact in so you can have a russia,people theyre coming on to this to,actually get the treatment and get cured,and so were getting a lot of pushback,from the governments insurance,companies and employers and pbms on,these high cost so you know this is,going into the you know really how over,the next two years youre going to see a,huge increase in price you know that,employers and insurance insurance,companies are going to have to bear the,burden of as you have the you know the,people that currently have XC go on the,drug and actually get your and then,youre going to see the profs slowly,start to you know decrease going forward,so if we look at state spending on the,and Hep C with cavaldi,what impacts more than pepsi impacts,more than 3 million Americans its a,degenerative disease of the liver you,know eventually youre going to need a,transplant its nationally more than,750,000 Medicaid patients and prisoners,or under state health programs suffer,from Hep C and its going to have its,gonna be one of the biggest burdens that,states are going to have that theyre,not funded for it and theyre not ready,financially to pay for it so one of the,nations largest Medicaid populations,California faces a 6.7 billion dollar,hepatitis C drug for the 93,000 Medicare,enrollees and prisoners that have the,disease so this is basically a cost of a,hundred and seventy four dollars per,resident in the state of California if,we lose look at Louisiana its got the,highest cost / on / residence at two,hundred ninety-four dollars in Florida,in New York could see nearly a four,billion dollar on each cost in hep-c,spending so this is massive implications,in Louisiana you know which is you know,the top five states with the highest per,capita spending and then you got,Delaware which is at $265 and its a,tipping at two hundred fifty nine,dollars per resident Oklahoma 223 in,Texas is 200 so the cost is really high,so w/e this is spreading the cost off,overall the residents of the state and,Medicaid may actually have to spend 55,billion dollars attacks their money just,the paper Hep C treatment with savants,of all d and its a big challenge is how,do you say were not going to cover it,because of you a Pepsi the previous,treatments might have had a 50-percent,ratio success sometimes low or higher,depending on what you had and this one,almost cures the condition so,everybodys going to want this everybody,is going to demand this and you notice,you know you have some states and even,private insurers who are looking to,restrict approvals Ivaldi and looking at,oh were only going to provide it for,people with advanced Pepsi liver disease,so you know,going to be a big controversy and fight,you know going going forward because at,the end of the day it comes down to,dollars and then you got to look at,whats going to be the out-of-pocket,costs ductable scone turns for employees,depending on how that structure whether,its fully insured or whether its self,self funded and then one of the,questions you have to ask today if any,of you werent following news because i,just did a health care reform webcast,with two of the top national attorneys,in health care reform but you have the,DC appeals court today basically saying,that the federal subsidies for the,exchanges are valid you know and then,that the IRS over overreached and you,know does that mean that the federal,subsidies subsidies now are no longer,valid and you know the 7 million people,on who came on to healthcare healthcare,reform coverage arent going to get,those subsidies are going to have to pay,those subsidies back you know its a,real problem because for those people,theyre going to want access to some,aldi are they going to be able to afford,health insurance now thats going to,cover so baldly treatment um so Gil we,add who is the maker of sorts of aldi,you know has argued that obviously its,going to save on future health care,costs by curing hefty patients and you,know they earned two point two seven,billion dollars in their first quarter,and theyre on pace to earn about five,billion dollars during the second,quarter of 2014 so this is going to be,one of the biggest moneymaker for them,and its production cost is a hundred and,thirty dollars a pill and theyre,selling it to us patients at basically a,thousand dollars to tell so a very big,markup and you know theyd hired a,consulting firm to look at where they,priced the drug in the US market and,that I believe that was around 32 or 34,thousand dollars and it was recommended,that they come into the US market with,that with that drug but its a cure so,theyve come at a much higher price,which is 84,000 now also you were seeing,where youre using the eliseo treatment,another drug in combination with,sovaldi or alesio being used with other,other things now if you use the OL ethio,with the 12-week treatment program,Alethea would cost 65,000 but if you,combine that with sovaldi it can be over,a hundred and forty thousand dollars and,if youre a patient and you FFC are you,going to say I just want sovaldi or I,want bolts Ivaldi and eliseo where Im,having even a higher chance of success,so now youre looking at costs for hep-c,at potentially a hundred and forty,thousand dollars because alesio alone,look you know its around an 80% jewelry,so savales development costs for for the,drug Julius was 11 billion dollars and,that gizelle open boss is going to be,recovered in the first year of their us,sales alone because theyre charging 84,thought for eighty-four thousand dollars,for treatment and why are they able to,do that well we you know I already said,its because you know of the high cure,rate and if someone doesnt get this,cure and they need a liver transplant,that can cost hundreds of thousands of,dollars and then the patients also,going the anti-rejection medication,which can cost forty thousand dollars a,year for the rest of their lives so for,some patients it could be millions of,dollars around that liver transplant so,they know if they can provide accurate,eighty-four thousand dollars they can,charge for it um and also you know,theres your arguments as congressional,hearings going on with this right now,regarding a you know the you know,Congress and a lot of have people doing,an outcry thing theyre charging too,much Gilead for this Ivaldi drawn and,you know and theyre making the argument,that the United States is subsidizing,the rest of the world so whats,i

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