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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

December 2015

PCSK9 Inhibitors: Prior Authorizations and Innovative Contract for Repatha

Harvard Pilgrim offers coverage of Repatha and Praluent, which are part of a new class of biotechnology medicines known as PCSK9 inhibitors, with prior authorization. These medications are used to treat elevated LDL cholesterol levels in patients whose levels are not adequately controlled by other treatment options and are given by injection every 2-4 weeks.

As our preferred PCSK9, Repatha is offered to members at a lower cost share. Repatha is covered on our Premium and Value formularies (Tier 2 in the Premium 3-tier; tier 3 in Premium 4-tier; tier 3 in Value 4-tier; tier 4 in Value 5-tier), while Praluent is covered on the Premium formularies only, at the highest tier (Tier 3 on the Premium 3-tier and Tier 4 on the Premium 4-tier).

Contract allows for member cost-saving

Harvard Pilgrim Health Care and Amgen Inc., the maker of Repatha, have negotiated an agreement that will help to slow the growth of escalating health care costs and improve care for patients.

This innovative contract contains a pay for performance guarantee through which Amgen is taking financial risk by providing the health plan with an enhanced discount if the reduction in LDL levels for Harvard Pilgrim members is less than what was observed during clinical trials. In addition to this guarantee, the agreement also provides for additional discounts if utilization of the drug exceeds certain levels. This enables those patients who can most benefit from the drug to receive it while continuing to encourage utilization of lower cost statins for the majority of patients.

“As the health care delivery system has moved away from paying fee-for-service toward paying for appropriate outcomes, the pharmaceutical segment has remained primarily in a traditional ‘pay for pill’ model,” said Harvard Pilgrim Chief Medical Officer Michael Sherman. “Agreeing to pricing models that align payment with appropriate outcomes is critical if we are to better manage increasing drug costs.”

Obtaining prior authorization

To learn more about Harvard Pilgrim’s clinical criteria for the usage of these medications, please refer to the PCSK9 inhibitors medication request guidelines. To obtain authorization, please complete the PCSK9 Inhibitors Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643.

These medications will be offered through Accredo as part of Harvard Pilgrim’s Specialty Pharmacy program. For more information, please refer to the Specialty Pharmacy Program section of our provider website.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator