Home Press Release Express Scripts Says It Will Cover 2 New Cholesterol Drugs

Express Scripts Says It Will Cover 2 New Cholesterol Drugs

Business Day

The nation’s largest manager of drug prescriptions said on Tuesday that it would pay for two drugs in a promising new class of cholesterol-lowering medicines, rather than choose one over the other in an effort to lower costs.

The pharmacy benefits manager, Express Scripts, and some others had expressed concern about the price of the drugs, Repatha from Amgen and Praluent from Sanofi and Regeneron Pharmaceuticals, both more than $14,000 a year. They said that with millions of Americans needing to further lower their cholesterol, the products, known as PCSK9 inhibitors, could become one of the largest drug categories, straining health care budgets.

Express Scripts created a stir late last year when it decided to pay for AbbVie’s new drug to treat hepatitis C, Viekira Pak, and not for Harvoni, a competing product from Gilead Sciences. Some other health plans followed suit in choosing only one of the two drugs, forcing Gilead and AbbVie to offer bigger discounts to retain sales.

Investors and cardiologists have been waiting to see whether health plans would try to force the same winner-take-all bargaining from the makers of the two new cholesterol drugs.

Express Scripts, at least, will not, saying Tuesday that it had received sufficient discounts to offer both products. However, it did not indicate what it would pay for the drugs or what consumers would pay, which depends on their health plan.

“We were able over the course of tough negotiations to get good economics on both products,” said Dr. Steven Miller, chief medical officer at Express Scripts.

The two drugs, approved this summer, have excited cardiologists because they can lower LDL cholesterol, the so-called bad form, by 40 percent or more, even when patients are already taking statins.

Health plans are still recovering from the rapid uptake in 2014 of Gilead’s new hepatitis C drugs.

Dr. Miller said that Express Scripts would prevent such a surge with the cholesterol drugs by strictly controlling who can use them, demanding proof from doctors that patients have high cholesterol and have already tried statins, which are mainly generic and far cheaper.

He said that Express Scripts had rejected about half the prescriptions. In some cases doctors did not even know the patient’s cholesterol levels, he said. In others, they said the patient had tried statins but Express Scripts did not have any record of the patient’s statin use.

Express Scripts said that employers and health plans that use its national preferred formulary, which manages prescriptions for 25 million people, would spend about $750 million on the new cholesterol drugs in 2016, less than industry forecasts. It said it had capped what clients would pay for the drug in 2016, meaning Express Scripts would eat any overruns.

“I believe we have really insulated our plan sponsors and patients for 2016,” Dr. Miller said. But he added that use could explode if new information shows that the drugs can prevent heart attacks, strokes and death, in addition to lowering cholesterol.

“Do I still think this can grow to the largest class of drugs in history?” he said. “Absolutely.”

CVS Health, the nation’s second-largest pharmacy benefits manager, has not released its decision on which of the cholesterol drugs it will cover.

Some insurers have issued policies on which patients will be eligible for the drugs.

Health plans typically offer to prefer some drugs over others in exchange for lower prices. This has generally been done by putting the nonpreferred drugs into a higher tier, meaning a higher co-payment.

But drug companies now routinely pay all or part of co-payments, reducing the effectiveness of co-payment tiers as a bargaining chip. So increasingly plans are willing to totally exclude non-preferred drugs from coverage, forcing the manufacturers into a winner-take-all bidding war.

While these tactics can lower costs, they can sometimes require patients to switch medications and give physicians and patients less choice.

Anthony C. Hooper, executive vice president for global commercial operations at Amgen, said in a statement Tuesday that his company was “delighted that Express Scripts has chosen to preserve physician and patient treatment choice.”

Leonard S. Schleifer, chief executive of Regeneron, said the agreement “demonstrates our commitment to working with payers to reduce costs and ensure appropriate patients can access this innovative medicine.”

The Institute for Clinical and Economic Review, an organization that evaluates drug costs, said last month that the new cholesterol drugs would have to cost no more than $4,800 a year to be considered cost-effective and no more than about $2,200 to avoid straining budgets. Amgen has strongly criticized the assumptions used in that analysis.

Dr. Miller said Express Scripts had not obtained discounts that big.


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