by Jinghong Chen
All PCSK9 inhibitors for patients with heterozygous familial hypercholesterolemia are covered under both the pharmacy benefit and medical benefit with some limitations, most frequently prior authorizations and quantity limits. In 2018, Express Scripts Holding Co., now part of Cigna Corp., struck a deal with the manufacturers of Praluent that will give the PBM a lower net price on the drug in exchange for streamlined patient access and an exclusive spot on the PBM’s national formulary. Overall, since last July, market access to Praluent for all payers under commercial and exchange formularies saw a significant decrease. For all four medications on the market, more than 60% of covered lives are under the preferred tier/preferred with prior authorization or step therapy and covered tier/covered with PA/ST. Payer pharmacy benefit formularies require ST for 93% of the covered lives and PA for 88% of the covered lives.
NOTE: Under the pharmacy benefit, the numbers of total covered lives under commercial, health exchange, Medicare and Medicaid formularies are 108.9 million, 10.2 million, 33.2 million and 62.0 million, respectively. Under the medical benefit, the numbers of total covered lives under commercial, health exchange, Medicare and Medicaid policies are 184.9 million, 10.2 million, 44.5 million and 62.0 million, respectively.
SOURCE: Managed Markets Insight & Technology, LLC database as of July 2018 and July 2019.