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When Lower Drug Prices Aren’t Enough

What happens when lower drug prices don’t make medicine more accessible for patients?  Heart patients covered by Medicare Part D are about to find out.

Last year, manufacturers of cholesterol-busting PCSK9 inhibitors cut the drugs’ sticker price by 60%.  But new research says that patients may still pay $100 or more a month for the medicine, which protects them from a heart attack or stroke.  

Why?  The answer lies with how health plans categorize prescription drugs.  

PCSK9 inhibitors used to be in what’s known as a specialty tier.  It’s health plans’ highest classification of drugs, typically reserved for expensive specialized medicines.  And it carries a hefty out-of-pocket cost to patients. Under Medicare Part D, beneficiaries pay 25-33% of a specialty tier drug’s list price out of pocket.  

When the prices of PCSK9 inhibitors were slashed, the drugs no longer qualified for the specialty tier.  This was health plans’ chance to shift the drugs to a “preferred” tier, home to less expensive medicines and more manageable co-pays.

But not all health plans took the opportunity to make the life-saving drugs more affordable for patients.  

Instead, many plans relegated PCSK9 inhibitors to the “non-preferred” tier.  As the name implies, this tier is typically reserved for drugs that have a lower-cost alternative preferred by the insurers.  Health plans place drugs on the non-preferred tier to discourage patients from using them. They do so by requiring patients to pay up to 50% of the non-preferred medicine’s cost.

The problem?  No lower-cost, “preferred” alternative exists for PCSK9 inhibitors. So seniors whose Medicare plans place the drug on the non-preferred tier have only two choices – pay up or go without.  

Those who take the latter path could face deadly consequences.  Research released earlier this year showed that patients who abandon their PCSK9 inhibitor prescription at the pharmacy counter face a 21% increased risk of a cardiovascular event.

Scores of Americans believe that lower drug prices would make their medicine more affordable and more accessible.  But heart patients are learning the hard way that health plan rules can turn commonsense on its head. Until Medicare plans can rectify the situation, some seniors could pay big – even with their lives.

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