The decision affects patients who have UnitedHealthcare insurance as well as for insurers who use the policy decisions of OptumRx, UnitedHealth's growing pharmacy benefit manager. Sanofi and Regeneron Pharmaceuticals make Praluent, a PCSK9 inhibitor that has been approved to treat specific groups of patients who have high cholesterol levels but don't respond to statins.
In exchange for placing prescription drugs on the preferred tier, which drives drug use, insurers usually receive discounts from the pharmaceutical companies. Financial details between UnitedHealth and the two drug companies were not disclosed.
"Helping our members access the drugs they need at an affordable price is our main priority as we develop our formularies each year," UnitedHealth said in a statement. "We rely on clinical guidelines and scientific evidence when making coverage decisions so that we can offer high-quality prescription drug coverage to our members."
The retail price for Praluent is $14,600 annually, while its competitor, Repatha, costs slightly less at $14,100. Rebates are highly guarded trade secrets, although executives at Gilead Sciences let it slip that the company offered discounts of roughly 50% for its high-priced hepatitis C drugs. Insurers and PBMs were engaged in a fierce pricing battle with drugmakers over hepatitis C drugs earlier this year.
But even a 50% rebate would not be enough to make the cholesterol drugs cost-effective, according to the Institute for Clinical and Economic Review. ICER, a not-for-profit research group, released a report in September that said the prices of Praluent and Repatha would have to drop by more than 80% to be considered a good deal for the healthcare system and patients.
In February, Health Affairs estimated the long-term use of PCSK9 inhibitors could cost $100 billion annually just among those patients where statins are ineffective.
The other major PBMs have finalized how the PCSK9 drugs fit into their formularies. CVS Health Corp. chose Repatha. Express Scripts Holding Co., the nation's largest PBM, approved both products.
Some health insurers adopt the formulary policies of their PBMs, but many also make their own drug policy coverage decisions. Harvard Pilgrim Health Care, based in Massachusetts, was the first to sign a value-based contract for Repatha. Aetna covers both but has not shown a preference for one over the other. Many Blue Cross and Blue Shield affiliates are still mulling their options as well.