PCSK9 inhibitors are a type of medication designed to lower levels of low-density lipoprotein (LDL) cholesterol. These drugs work by inhibiting a specific protein, PCSK9, which naturally degrades LDL receptors on liver cells. By blocking this protein, PCSK9 inhibitors increase the number of LDL receptors available, thereby enhancing the liver’s ability to remove LDL cholesterol from the bloodstream. This class of injectable medications is typically prescribed for individuals with a high risk of cardiovascular events, especially when other cholesterol-lowering therapies, such as statins, have not been effective enough or are not tolerated.
Understanding the List Price
The list price, also known as the wholesale acquisition cost, represents the manufacturer’s suggested price before any discounts, rebates, or insurance contributions are applied. For evolocumab (Repatha), the list price is approximately $572.70 per month, which totals around $6,872.40 annually. Alirocumab (Praluent) has an annual list price of approximately $5,850.
The list price is rarely what an individual patient actually pays. These medications are high-priced due to significant investment in research and development. While the list price can appear substantial, various factors can reduce the actual cost for consumers. The cost of these medications has seen reductions since their initial introduction to the market, reflecting evolving pricing strategies.
Factors Affecting Your Out-of-Pocket Expense
Health insurance coverage plays a significant role in determining out-of-pocket costs. Most commercial insurance plans, along with Medicare and Medicaid, offer some level of coverage for these medications. Insurance plans utilize formularies, which are lists of prescription drugs they cover. These formularies are typically organized into tiers, with each tier corresponding to a different cost level for the patient. Specialty drugs, like PCSK9 inhibitors, are often placed in the highest tiers, which means they come with higher out-of-pocket expenses.
A deductible is the amount of money an individual must pay for covered healthcare services before their insurance plan begins to pay. Once the deductible is met, copayments and coinsurance come into play. A copayment is a fixed dollar amount paid for a prescription at the time it is filled. Coinsurance, conversely, is a percentage of the cost of the medication that the patient is responsible for after their deductible has been satisfied. For specialty medications, coinsurance is more commonly applied than a flat copay, meaning the patient pays a percentage of the drug’s cost.
Additionally, many specialty drugs require prior authorization from the insurance company, which is an approval process to determine medical necessity before the drug is covered. Without this approval, patients may be responsible for the full cost of the medication.
Navigating Financial Assistance and Support Programs
Manufacturers of these medications often provide patient assistance programs (PAPs). The Amgen Safety Net Foundation, for instance, offers free Repatha (evolocumab) to eligible patients who are uninsured or underinsured, based on financial need. Similarly, the MyPRALUENT Patient Assistance Program can provide Praluent (alirocumab) at no cost to eligible uninsured patients or those with insurance that does not cover pharmacy benefits, although new Medicare Part D enrollees may not be accepted.
Another common form of support comes through manufacturer-sponsored copay cards or coupons. For commercially insured patients, the Repatha Co-Pay Card can reduce monthly out-of-pocket costs to as little as $5 or $15. This card can cover various out-of-pocket expenses, including copayments, coinsurance, and deductibles, up to a specified annual maximum. Similarly, commercially insured patients using Praluent may pay as little as $50 per month with the MyPRALUENT Copay Card, subject to an annual maximum of $3,500. These copay cards are generally not valid for individuals enrolled in government-funded healthcare programs like Medicare or Medicaid.
Beyond manufacturer programs, various non-profit organizations and charitable foundations offer financial assistance for prescription medications. Organizations such as the Patient Advocate Foundation’s Co-Pay Relief, the Patient Access Network Foundation, and the HealthWell Foundation Copay Program may provide support. Eligibility for these programs often depends on factors such as insurance status, diagnosis, and income levels. Patients can also explore prescription discount websites, which may offer coupons that reduce the cash price of the medication, though these typically cannot be combined with insurance benefits.