2.2.20

Insurers are making it hard for patients to get access to this life-saving drug

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By Dr. Ali HaiderAs a cardiologist, most of my patients come to me for treatment and prevention of cardiovascular disease, the leading cause of death in the nation and the cause of over 18,000 deaths

As a cardiologist, most of my patients come to me for treatment and prevention of cardiovascular disease, the leading cause of death in the nation and the cause of over 18,000 deaths in New Jersey each year.



Many of these deaths are preventable through improved diet, exercise, and, of course, proper medication.

In recent years, however, too many insured patients have had trouble accessing the medications that we physicians prescribe – most of whom are Medicare beneficiaries on fixed incomes.

By now, the ways insurers limit patient care are familiar: exorbitant cost sharing requirements for patients, or bureaucratic red tape creating an uphill battle for physicians to use the FDA-approved medications of their choice.

This includes resource consuming prior authorizations or “fail-first” step therapy regimens that patients must endure before insurers will cover the drug their doctor prescribed – even when it may be the superior choice and supported by clinical guidelines. Such barriers to treatment created by non-clinicians are extremely frustrating for us physicians.

But in cardiovascular health, this trend is especially pronounced – and to a dangerous degree.

For decades, patients with high cholesterol have relied on statins to decrease their risk. However, there are many patients for whom this is not enough. A newer drug class, known as PCSK9 inhibitors, can dramatically reduce cholesterol levels for the roughly 10 million Americans who don’t adequately respond to statins or cannot tolerate them, and remain at risk for heart attacks.

But because of the higher price of PCSK9s –some insurance companies will seemingly do anything to prevent patients from accessing them even when if there is no other option to reduce their cholesterol and future risk of events.

In fact, insurers rejected PCSK9 prescriptions 80 percent of the timeon the first attempt, and more than half the time on subsequent attempts. In 2017, almost 3,500 New Jerseyans’ insurance companies rejected the PCSK9s their doctor prescribed.

Even Medicare beneficiaries, who account for about half of all PCSK9 prescriptions, struggle with access. In fact, high cost sharing requirements imposed by Part D plans have led most Medicare patients to abandon their PCSK9 prescriptions altogether.

This has created a dire situation.

Data shows that those who are rejected or abandon their medication are up to 21% more likely to suffer a heart attack or stroke.

What can be done? Should part of the blame lie on the drug manufacturers in making their medicines so expensive?

Certainly. In fact, they took notice that cost was standing between patients and their life-saving prescriptions, and last year, the manufacturers of PCSK9s reduced their prices by 60%.

Astonishingly, though, most commercial and Medicare plans have still not made PCSK9s more affordable.

After drug companies did their part, why cannot Medicare follow suit?

While Medicare Part D plans have removed PCSK9s from their “specialty tier” after the large price reduction, a recent analysisby Avalere Healthcare found that most Part D drug plans have simply shifted the drug to “non-preferred tiers,” where cost-sharing can be even higher than the specialty tiers –up to 50% of a drug’s list price, compared to a maximum of 33% on the specialty tier.

In New Jersey, up to 80% of Part D beneficiaries in will only be able to access their PCSK9 prescriptions on non-preferred, higher cost-sharing tiers in 2020.That’s not right for patients.

New Jersey Rep. Chris Smith has championed the need greater, more affordable access to PCSK9 inhibitors. I applaud his efforts, but still more must be done.

I hope New Jerseyans will join me in encouraging them to keep up the fight.

While policy changes to ensure lower out-of-pocket costs at the pharmacy counter for those on commercial plans may take time, steps can and must be taken immediatelyfor Medicare beneficiaries.

Given that PCSK9s are proven to prevent heart attacks and strokes and are supported by clinical guidelines, Medicare should require Part D plans to make them available to appropriate patients not on a non-preferred tier, but at an affordable, fixed co-pay – today.

Doing so can and will save lives.


Ali Haider, MD, FACC, FSCAI, is a native New Jerseyan. He isa cardiologist at Hampshire Cardiology Associates and an Assistant Professor of Medicine of Tufts University Medical School.

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