Less Than Half of PCSK9 Prescriptions Get Insurance Approval

Recent research in Circulation found that less than half of patients prescribed PCSK9 inhibitors receive approval from their insurer to cover the drug.

PCSK9 inhibitors have recently been the center of controversy regarding cost-effectiveness. Repatha (evolocumab; Amgen) and Praluent (alirocumab; Sanofi/Regeneron) are both priced around $14,000—much higher than other cholesterol-lowering drugs. Therefore, prescriptions for PCSK9 inhibitors often require pre-authorization from insurance plans. Early this year, ICER determined that despite the marked reduction in low-density lipoprotein (LDL), PCSK9 inhibitors are not cost-effective at their current price.

“With the controversy surrounding whether or not these drugs were cost effective, we were anticipating that there might be some reluctance by insurance companies to cover these medications," Robert Yeh, MD, director of the Smith Center for Outcomes Research in Cardiology at the Beth Israel Deaconess Medical Center, said in a press release. “However, we were surprised by the very high rate of rejection, even when prescribed to patients with known atherosclerotic cardiovascular disease, very high LDL levels and those who were intolerant of statins, for example.”

The researchers completed a nationwide review of pharmacy claims and EHRs for 9,357 patients who were prescribed PCSK9 inhibitors by a physician between July 2015 and August 2016.

Dr Yeh and colleagues found that only 47% of prescriptions were approved and 53% were rejected by insurance plans. They also found that the most correlative factor affecting authorization was insurance type. Patients with private insurance had the lowest rates for approval while patients with Medicare had the highest.

“Whether or not we can agree on the cost-effectiveness of these drugs, I believe most would agree that one's access to medications should be driven primarily by the strength of the indications for the prescription as opposed to what drug plan you happen to carry,” Dr Yeh said.

—David Costill

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