Perspective on the Rx Pipeline - Shingrix
Shortly after the Food and Drug Administration’s (FDA’s) approval of Shingrix for the prevention of herpes zoster (shingles) on October 20, 2017, the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) voted to recommend the vaccine over Zostavax® for adults 50 years of age and older. The group also voted in favor of immunizing this adult population with Shingrix even if they have already been vaccinated with Zostavax.
This is the first time this committee has ever shown preferential status for a specific brand product.
From chickenpox to shingles: Shingles comes from the same virus that causes chickenpox and in fact, you can only get shingles if you’ve had chickenpox. As you age, your immune system becomes weaker and the chickenpox virus that was lying dormant can move from your nervous system to your skin as a painful, blistering rash. Even after the rash is gone, people commonly experience post-herpetic neuralgia, or severe pain in areas of the rash, as a long lasting complication.
Highly prevalent with a hidden impact on employers: The CDC reports that one out of every three people in the U.S. will develop shingles, which costs approximately $1 billion in direct and indirect medical expenses each year. It also results in an average of three weeks of missed work per patient per episode.
Shingrix vs Zostavax: Zostavax is a live attenuated vaccine and Shingrix is a recombinant adjuvanted vaccine. A live attenuated vaccine uses a small protein from the live virus to trigger the immune system to mount a defense against the virus, whereas a recombinant adjuvanted vaccine uses a protein that is created in a lab using genetic material to simulate the virus. As a result, the Shingrix vaccine has fewer restrictions of patient populations, such as people with immunosuppression issues or who are pregnant, and it boosts effectiveness. Shingrix is a two-dose vaccine series given two to six months apart intramuscularly versus the one-dose of Zostavax administered subcutaneously.
In clinical studies, Shingrix showed similar effectiveness in all age groups and had much higher rates of effectiveness compared to Zostavax, which has a marked decrease in efficacy in the older population. Based on CDC estimates, the effectiveness of Shingrix in patients 60-69 years old was 97%, while it was only 64% for Zostavax. In patients over 80 years old the difference is much more dramatic, with an estimated efficacy of 91% for Shingrix and only 18% for Zostavax.
Impact to the Pharmacy Care Experience
Formulary: Due to the superior clinical effectiveness of the new vaccine, along with the recommendations of the ACIP, EnvisionRx is moving Shingrix to a preferred tier. This indicates that the new vaccine should be the first option for protection against an active shingles infection and post infection complications. By providing a simpler path for members to receive the superior product, occurrences of the disease can be decreased, along with the cost burden.
The cost for a single injection of Zostavax is approximately $233 and the price for a two-dose series of Shingrix injections will be about $280. While the cost of the Shingrix vaccine is more, those receiving Zostavax would have to be re-vaccinated with Shingrix, making Shingrix more cost effective.
Member Engagement: Even though Shingrix costs slightly more than Zostavax, with Shingrix in a preferred tier, members may actually receive a lower cost share for using Shingrix in order to encourage them to choose this more effective option. By moving Shingrix to a preferred status, EnvisionRx is also reducing the number vaccines a patient will need and providing better protection against the disease. Additionally, because the vaccine design has fewer limitations on the patient populations who can receive it, the treatment is more accessible to members. Similar to Zostavax, Shingrix can be administered by doctors or pharmacists at retail locations, including Rite Aid.
Clinical: Shingrix should be administered to patients over 50 years of age, regardless of their immunization history with Zostavax. Shingrix can be given as soon as eight weeks after Zostavax was administered.
Payer Action Plan
Review plan: EnvisionRx recommends that plan sponsors review their coverage policies on vaccinations to ensure that shingles prevention is available to members. It is also important to review policies to verify if the plan design for vaccine coverage is in the correct benefit (medical vs. pharmacy) based on cost/reimbursement. Please note, for those using EnvisionRx formularies, Shingrix has been assigned to a preferred tier and no action is required.
 Centers for Disease Control and Prevention. (October 2017). Herpes Zoster Vaccination Information for Health Care Professionals. https://www.cdc.gov/shingles/hcp/clinical-overview.html
 Centers for Disease Control and Prevention (October 2017). About Shingles (Herpes Zoster). https://www.cdc.gov/shingles/about/overview.html
Our Clinical Steering Committee
The Envision Clinical Steering Committee brings together leaders across our national pharmacy care company to monitor the drug landscape, provide recommendations on how to address changes, and to ensure our clients and patients are prepared—in advance.
With any new development, we partner with our Pharmacy & Therapeutics (P&T) Committee and consult with our best-in-class specialty pharmacy, to provide a balanced perspective on the clinical effectiveness of all available options, the cost impact to our plan sponsors and patients, and the impact on the overall patient experience.
Kel Riley, MD
Chief Medical Officer