UPDATE: UnitedHealth, the nation's largest private health insurer, announced on Friday that its main benefits manager unit, OptumRx, will list Sanofi/Regeneron's Praluent as the preferred PCSK9 cholesterol-busting drug on its formulary over Amgen's competing Repatha. The insurance giant had previously announced that its Oxford unit (which covers patients in the northeast U.S.) would favor Praluent.
It's unclear at this point whether or not Repatha will be available as an alternative (and potentially more expensive) option for OptumRx customers who do not respond to a course of treatment with Praluent, as is the case with the Oxford unit. But one thing's for sure: Sanofi/Regeneron and Amgen have their work cut out when it comes to the pursuit of prescriptions for the next-gen cholesterol meds.
Contrasting with UnitedHealth, CVS has chosen to list Repatha as its preferred option, while the nation's largest PBM (Express Scripts) struck deals to list both treatments on its formulary after winning discounts from the drugmakers.
- UnitedHealth's Oxford unit, a PBM which covers patients in the northeast U.S., is positioning Sanofi/Regeneron's Praluent (alirocumab) as the first choice for patients with high cholesterol that requires treatment with a PCSK9 drug (UPDATED ABOVE).
- If Praluent doesn't work after 12 weeks, patients can switch to Amgen's Repatha (evolocumab).
- Since the drugs were approved by the FDA this past summer (Praluent was approved in July and Repatha was approved in August), they have been competing for first-tier positions on large formularies. Both drugs are priced at roughly $14,000 per year and associated with a 60% reduction in LDL-C.
For several months, Sanofi/Regeneron and Amgen have been vying for first-tier formulary positioning. Last month, CVS Health decided to go with Amgen's Repatha, which was also tapped for first-tier positioning in Harvard Pilgrim Health System's formulary.
As for Express Scripts, the largest pharmacy benefits manager (PBM) in the U.S., the decision was made to cover both drugs after the company scored discounts from the drugmakers; however, prior authorization requirements make it difficult for patients to procure either drug unless they meet strict criteria.
Although Amgen seems to be in the lead so far, UnitedHealth's OptumRx PBM is still unspoken for (UPDATED ABOVE). At the same time, in the current climate, both drugs are at a disadvantage as payers look towards the most affordable treatment options (in this case, statins are the most affordable go-to medication for high cholesterol).
Even when patients meet all of the criteria for treatment with a PCSK9 drug, many payers in the U.S. and the E.U. are waiting for data showing an actual cardiovascular (CVD) benefit in the form of a reduced risk of certain CVD events before becoming more permissive about covering these drugs. In the meantime, the companies will continue grinding it out in the benefits manager market.