Out-of-pocket spending on chronic hepatitis B treatments remains high


While the cost of treating chronic hepatitis B (CHB) has decreased somewhat in recent years, the out-of-pocket costs remain high and burdensome for some patients.

A team led by Jonathan D. Alpern, MD, HealthPartners Infectious Diseases, assessed trends in the number of manufacturers, average wholesale price, National Average Drug Acquisition Cost (NADAC), and out-of-pocket expenses for entecavir in a commercially insured patient population with CHB between 2014-2018.

The cost of treating chronic hepatitis B

While CHB is treatable and inexpensive in the US, high out-of-package expenses for first-line therapies could be a treatment barrier preventing better care.

On the positive side, entecavir, a first-line treatment for CHB, has seen a sharp drop in the average price pharmacies pay due to manufacturer competition.

However, the list price has remained high.

The study

In the cross-sectional study, investigators determined annual NADAC prices of entecavir 0.5 mg tablets using Medicaid’s publicly available NADAC database for the last week of December 2014 through December 2018.

The team calculated the annual average wholesale price based on a weighted average calculation of Medicaid expeditions and an average wholesale price derived from a standard drug database.

Investigators also used the US Food and Drug Administration’s Orange Book to determine the annual number of drug manufacturers and analyzed a commercial database of health claims using a cloud-based analytics interface from 2014 to 2018.


In total, there were 1,000 annual entecavir fills between 2014 and 2018, with a mean of 6.7 annual fills per member. As the number of entecavir manufacturers increased from 1 to 11, the NADAC price fell from $30.12 to $1.93 per 0.5mg tablet.

Wholesale prices remained steady at $44.43 on average.

Additionally, average self-expenses per 30-day supply of generic entecavir were US$41 in 2014 and US$52 in 2018 for commercially insured members.

However, for members with a high-deductible plan, the average out-of-pocket expenses per 30-day supply of generic entecavir were $103 in 2014 and $133 in 2018.

Average total spend per 30-day supply of the generic version was $981 in 2014, compared to $591 in 2018.

“Own spending on generic entecavir increased between 2014 and 2016 and remained high through 2018, despite robust generic competition and a significant decrease in the price pharmacies paid for entecavir,” the authors wrote. “The artificially high average wholesale price of entecavir is a likely reason for such high captive spending, as drugs are often paid for on the basis of a discount to the average wholesale price, which benefits middlemen in the supply chain – such as e.g. e.g. pharmaceutical benefit managers and wholesalers – while contributing to drug price inflation.”

Several limitations were noted in the study, including the lack of health insurance discounts or patient coupons in the expense calculation. Investigators did not consider other strategies, including pill-splitting 1 mg tablets, that could reduce out-of-pocket expenses.

The team also said the study underscores the importance of policies that improve transparency around generic drug funding and the practices of pharma benefit managers.

The study “Trends in Pricing and Out-of-Pocket Spending on Entecavir Among Commercially Insured Patients, 2014-2018” was published online in JAMA network open.


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