ICER says Pfizer's Paxlovid, Merck's molnupiravir both cost effective, but their benefits are far from equal

Weighing three outpatient treatments for COVID-19, the drug cost watchdog Institute for Clinical and Economic Review (ICER) has determined that Pfizer’s Paxlovid, Merck and Ridgeback Biotherapeutics’ molnupiravir and generic fluvoxamine all carry reasonable prices—but that’s not to say they are equal.

An ICER committee voted (PDF) 11-2 that the evidence on molnupiravir was inadequate to demonstrate a net health benefit over symptomatic care alone. Paxlovid, for its part, won all panelists’ favor with 13 votes, while a slight majority of panelists (7 to 6) found current evidence on fluvoxamine acceptable to demonstrate benefit over symptomatic care.

Meanwhile, all three meds fell within acceptable price ranges, ICER noted. Given the “uncertainty” of molnupiravir’s net health benefit, a majority of panelists voted that it represents “low-to-intermediate” long-term value for money. Most panelists voted that Paxlovid represents “high” long-term value, and a majority said fluvoxamine offered “intermediate-to-high” long-term worth.

A treatment course of Merck and Ridgeback’s molnupiravir runs for $707, according to ICER. One Paxlovid course costs $529, while fluvoxamine costs just $12 per course. Fluvoxamine is a selective serotonin reuptake inhibitor that won approval in 1994 to treat obsessive compulsive disorder. The drug's anti-inflammatory effects are being studied in COVID, the National Institutes of Health says.

While ICER viewed the existing clinical evidence as more favorable to Paxlovid and fluvoxamine, all three drugs are in ongoing clinical trials, Steven Pearson, M.D., ICER’s president, noted in a statement.

“At their current negotiated price (molnupiravir, and Paxlovid) or their generic market price (fluvoxamine), these drugs appear to have prices reasonably aligned with patient benefits,” Pearson added.

One “key lesson” to take away from the trio’s development is that the U.S. government's advance purchase framework “was effective in reducing the financial uncertainty that could have deterred manufacturers from bringing a drug to market, and ultimately resulted in multiple drugs becoming available in a relatively short time at prices that were aligned with clinical benefit,” the ICER president said.

Federal policymakers should treat the U.S.' advance market commitment strategy “as a success that should be built upon” in the event of future health emergencies, ICER said.

That isn’t to say there aren’t pricing lessons to be learned, however.

The pandemic pricing framework between drugmakers and the government ought to be “more transparent,” ICER argued. The federal government also needs to work with policymakers and states to “adopt policy changes needed to improve the effectiveness of its “test-to-treat” program,” the watchdog added.

Finally, when the pandemic market shifts to private, drugmakers and payers should team up to “explore innovative approaches for coverage and pricing," that don't require "restrictive" access, ICER concluded.

Pfizer’s Paxlovid turned in $1.5 billion in first-quarter sales, the company said last week. Nevertheless, Pfizer still expects its oral antiviral will snare roughly $22 billion this year. The drug may soon get a boost from contracts in Europe and China, plus, the U.S. recently stepped in with plans to purchase 20 million courses of the drug and chip in on manufacture and supply of the pill.

Molnupiravir, for its part, clocked first-quarter sales of $3.2 billion, eclipsing Wall Street’s expectation by $500 million. For the full year, Merck forecasts molnupiravir revenues between $5 billion and $5.5 billion, slightly down from its previous guidance of $5 billion to $6 billion.