Trends in Cholesterol Management Show Payers Prefer Cheaper Generics

According to a presentation by Richard Brook and colleagues, payers are likely to favor less expensive, generically available agents until real-world data provides justification for use of PCSK9 inhibitors. 

“We noted the changing trends in the market, on one hand, we saw the entrance of the PCSK9s and their relatively slow update in the market, while on the other hand, most of the older line cholesterol agents are now generically available,” Mr Brook, president of Better Health Worldwide, Inc, and coauthor of the study, told First Report Managed Care. 

The researchers surveyed 52 medical directors and pharmacy directors who worked for health plans, pharmacy benefit managers, government agencies, and consultant firms. Among the participants who worked at health plans, their payers represented national, regional, and local coverage tiers covering commercial, Medicaid, Medicare, and employer/self-insured members. 

Mr Brook and colleagues found that PCSK9 inhibitors had the highest prior authorization rate compared with other cholesterol management agents, with 92.7% of medical directors responding that they required prior authorization. 

“Based on the US population and the changes from the National Cholesterol Education Program (from a target based approach with specific numbers) to a patient-based approach, almost everyone in the US could benefit from cholesterol management,” Mr Brook explained. “Unfortunately, as has been shared in many NASP presentations, adherence to medications—especially those for asymptomatic conditions like high cholesterol, is not where it needs to be. 

Results also found that statins with generic options ranked highest among first tier preferred treatments. Additionally, combination cholesterol-agents and cholesterol/cardiovascular combinations were mostly in tier 2.

Mr Brook and colleagues also noted that fish oil was among the unrestricted generic cholesterol treatments. 

“While over-the-counter fish-oil products and supplements were generally unrestricted in
Medicaid plans, not covered by commercial or Medicare plans; the prescription therapy icosapent was PA-restricted by 28.2% of plans,” they wrote. 

He added that adherence remains a major issue with cholesterol management. “Plans are doing the best possible to make these medicines affordable, however the patient needs to take them!”

In his presentation, Mr Brook said that as more effective cholesterol management products come to the market, plans are likely to exclude those drugs unless better efficacy data are released with them.

  “As new products enter the cholesterol management market, health plans will likely impose restrictions and plan designs on new classes
favoring less expensive, generically available agents until real-world effectiveness data becomes available. ” Mr Brook and colleagues concluded.

—David Costill