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Two members of Congress are speaking out on behalf of Medicare patients with cardiovascular risk.

In a recent letter to the Centers for Medicare and Medicaid Services, Rep. Joyce Beatty (D-Ohio 3rd district) and Rep. Christopher Smith (R-NJ 4th district) called for more affordable access to PCSK9 inhibitors for seniors.  The medications lower stubborn LDL, or “bad”, cholesterol when patients haven’t adequately responded to other drugs.

Reps. Beatty and Smith, co-chairs of the Congressional Heart & Stroke Coalition, are concerned seniors don’t have lower out-of-pocket costs, even after manufacturers cut the drugs’ prices by 60%.  “Patients are still experiencing barriers to this innovative class of medicine,” the representatives explain in their letter to CMS Administrator Seema Verma.

The challenge lies in how Medicare plans categorize the drugs.  In August 2019 Administrator Verma announced that PCSK9 inhibitors, with their price significantly lowered, should no longer appear on health plans’ specialty tiers.  The specialty tier is the highest category in a health plans’ hierarchy of covered drugs, reserved for expensive medicines. The tier requires high cost-sharing for patients.

Health plans complied.  But rather than moving the drugs to a preferred tier, which would require a flat, manageable co-pay for patients, some moved the drug to a non-preferred tier.  As the name suggests, this category is for drugs that do not provide a financial advantage to insurers. It too carries a heavy out-of-pocket burden for patients.

The move was “at odds” with the spirit of Verma’s announcement, Reps. Beatty and Smith argue in their letter.  “…Only one-third of patients will have access to PCSK9s on a preferred brand tier—where cost-sharing is typically the most affordable,” their letter notes.  The members of Congress urge the Centers for Medicare and Medicaid Services to “further clarify with the Part D plans…to help improve affordability for our seniors.”

By placing PCSK9 inhibitors on the non-preferred formulary tier, health plans may still require cost sharing of $100 or more from seniors.  Patients who forego treatment because they cannot afford it face a 21% increased risk of heart attack or stroke.

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