PCSK9 Inhibitors and the Public Exchange: What’s next?

Since the Health Insurance Marketplace (HIM) opened in 2014, a whole new population of health care consumers has emerged. Since its beginning, Prime Therapeutics (Prime) and our Blue Cross and Blue Shield Plan owners and clients have proudly served nearly 2 million public exchange members. This accounts for more than one in six of those who enrolled. As this marketplace matures, we have continued to analyze this population to learn how these new health care consumers use medicine.

Use of the top 10 drugs has remained relatively consistent. But spend has shifted significantly. Specialty medicine use and spend continues to increase. This is due in large part to newer, more effective — and more expensive — hepatitis C drugs and other biologic medicines. And public exchange members skew older than the commercial population. This, coupled with the introduction of new ultra-expensive, PSCK9 inhibitors, could push spend in this segment even higher.

By August 2016 (one year post-launch), approximate per member per month (PMPM) costs for PCSK9 inhibitors could be between $1.34 and $10.31. This increase could total between $2.5 and nearly $20 million in spend.1

Future impact

Based on estimated cases of heart disease and high cholesterol in this population, we determined that these new PCSK9 inhibitors could significantly affect spend among public exchange members. By August 2016 (one year post-launch), approximate PMPM costs for PCSK9 inhibitors could be between $1.34 and $10.31. This increase could total between $2.5 and nearly $20 million in spend.1

Given the cost — and the number of public exchange members who may be eligible for PCSK9 inhibitors — these new drugs pose a threat to health care affordability.  

Prime is working to manage the high cost of PSCK9 inhibitors by optimizing statin therapy. Today, all of Prime’s clients are aligned with successful PCSK9 strategies. But managing drug costs is just one piece of the puzzle. Proactively managing care is just as important. Effective utilization management strategies and support to drive adherence can help make sure the right people get the right medicine at the right time — which results in improved health outcomes and a lower overall cost of care.

Prime is dedicated to proactively managing pharmacy costs. This helps keep health care affordable, improves member outcomes and creates a more sustainable health care system.

We don’t know what the future holds for the HIM. But we know our focus remains strong. We will work to help you control costs so we can help people get the medicine they need to feel better and live well.

Read Prime's third report on the HIM.

Next: Prime Joins Campaign for Sustainable Rx Pricing

  1.  K.L. Bowen, P.P. Gleason. (2015). PCSK9 inhibitors Utilization Forecast Health Insurance Marketplace (HIM) Public Exchange.
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