Overview

This interview with a senior officer of a major insurer focuses on how payors will manage the introduction of PCSK 9 inhibitors. In the diabetes indication, the officer also comments on insulin biosimilars and touches on tiering of SGLT2/DPP4 inhibitors.

Highlights

PCSK9 Inhibitors

• Pre-authorization will require patients have tried a statin and likely ezetimibe, with differences in large versus small plans.
• Payors should be able to effectively prevent off-label use in patients without Heterozygous FH or clinical atherosclerotic cardiovascular disease (ASCVD).
• Plans will be more aggressive with prior authorization if they do not achieve good discounts in price negotiations.
• Differences in Medicare and commercial plan regulations can impact ability of pharmas to mitigate patient out-of-pocket costs.
• Payors are still figuring out how to handle the larger number of patients that could become eligible after the CV outcomes trials lead to broader labels. They will be very aggressive on statin intolerance.

Diabetes

• No special tiering for SGLT2/DPP4 FDCs. In some cases, they could end up on a preferred tier with the single drug components.
• Given steep price increases in insulin, plans are looking forward to more competition in the space.
• Currently, insulins may not be restricted as much as other products, but the introduction of biosimilars could lead to more tiering/step therapy.