Introduction
Atherosclerotic Cardiovascular disease (ASCVD) is the leading cause of death worldwide, and uncontrolled lipids are a major modifiable risk factor for ASCVD.1 Statin therapy remains the cornerstone for ASCVD risk-reduction, yet optimal lipid control remains suboptimal.2 Current U.S. guidelines recommend adding non-statin medications in patients whose LDL-C or non-HDL-C remains above specific thresholds despite maximally tolerated statin therapy.3,4 Non-statin medications, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies (evolucumab and alirocumab), small interfering RNA (siRNA) inclisiran, and the adenosine triphosphate-citrate lyase (ACL) inhibitor bempedoic acid are effective in lowering LDL-C, but their cost and the stringent authorization process may prohibit patient use. Previous survey data have found that 1 in 8 patients with ASCVD are non-adherent to medications due to cost.1 The purpose of this article is to provide practical recommendations on cost-saving strategies to help patients afford lipid-lowering therapies to lower atherogenic cholesterol levels and reduce ASCVD risk.
Available Generic Lipid-Lowering Medications
Several classes of lipid-lowering medications are available as generic medications, including statins of course, leading to lower drug costs for patients with and without prescription drug insurance. That said, despite being available as generic medications, some statin and non-statin medications may still require a substantial copay and may be unaffordable to some patients. There are several potential options to reduce the cost for generic lipid-lowering medications including pharmacy coupon cards and using affordable pharmacies to fill generic prescriptions.
Pharmacy coupon cards
Numerous pharmacy coupon cards (GoodRx, WellRx, SingleCare) are available for patients with and without prescription insurance but cannot be used in addition to prescription insurance.5 These coupon cards are typically free to patients and can be used to reduce costs of both branded and generic medications. Several coupon cards are also available as an app to compare drug prices at local participating pharmacies.
Alternate pharmacies
Select pharmacies, depending on the geographic region, offer many generic medications at low-cost which may be especially useful for patients without insurance or those with a high copay despite prescription coverage.
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Walmart pharmacy offers a fixed price for several lipid-lowering medications (simvastatin, gemfibrozil, fenofibrate) as 30 or 90-day supplies.6
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Kroger pharmacy also offers low-cost 30 and 90-day supplies of several statins (atorvastatin, pravastatin, simvastatin).7
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The Mark Cuban CostPlus online pharmacy is another option to save on generic lipid-lowering medications, including most statins, ezetimibe, and omega-3 acid ethyl esters.8 Patients must create an account for this online pharmacy and pay a small monthly fee.
Other options for cost savings
Patients treated for hyperlipidemia are likely to have other comorbid conditions, such as hypertension and diabetes. Utilizing combination medicines which contain two or more medications in a single pill may be another way to reduce costs by requiring only one copay. Multiple combination pills are available to treat hypertension and diabetes. There is even a combination product which includes atorvastatin and the commonly used antihypertensive agent amlodipine and is available as a generic formulation.
Manufacturer Coupons
Medication cost assistance is available from U.S. pharmaceutical manufacturers for most brand name medications dispensed from a pharmacy in the form of prescription drug discount coupons. These coupons may include one-time vouchers for a 30-day free trial and subsequent savings cards, which allow for savings up to a designated dollar amount each month.9 Re-enrollment is required on a periodic basis, typically annually.
Manufacturer coupons are only available for patients with commercial insurance plans and cannot be used for patients enrolled in state or federally funded insurance plans (i.e. Medicare Part D, Medicaid, Medigap, Veterans Affairs, Department of Defense programs, or TriCare) due to potential violation of federal anti-kickback statutes.10 Certain states, including Massachusetts and California, have banned the use of copay coupons on prescription medications with a generic equivalent to lower prescription drug costs by discouraging use of high-cost branded drugs.11,12 Medications without generic equivalents, including the PCSK9 modulating therapies and other agents listed in Table 1, are excluded from these regulations.
Inclisiran is not dispensed from a pharmacy, but covered as a medical benefit during an outpatient visit when the medication is administered by a healthcare provider. Any final cost to patients with commercial insurance plans may be eligible for reimbursement through the inclisiran co-pay assistance program, which can be submitted by the patient or provider.13 Similar copay assistance is available for evinacumab Evkeeza.14
Patient Assistance Programs
Patient Assistance Programs (PAPs) sponsored by drug manufacturers are a resource to help patients with limited income receive branded medications for little or no cost. Importantly, PAPs can be used for patients with a variety of prescription drug coverages, including Medicare D prescription drug insurance.15 This allows for continued access to medications even when patients reach the coverage gap (or “donut hole”) and are responsible for 25% of drug costs.16 Some programs may allow patients with commercial insurance or those who are uninsured to apply as well. Most PAPs determine patient eligibility based on annual household income and require submitting proof of income with the completed PAP application. These programs require annual renewal to confirm patients still meet eligibility requirements.
Other Assistance Programs
340B drug pricing
Healthcare organizations and hospitals who provide care to low-income and indigent populations may be eligible to purchase branded medications at a discount through the 340B drug pricing program.17 Outpatient pharmacies affiliated with 340B-eligible organizations can dispense these medications at little to no cost for patients served by the healthcare organization. The 340B programs may be hugely effective when they are available, and their benefits are applied. Medications administered by healthcare providers may also be available at substantially lower costs through 340B pricing.
Medicare part D Extra Help
For patients with Medicare D prescription insurance, drug copays may still be unaffordable especially when a patient enters the “donut hole”. The Medicare D Extra Help is a program available to patients with Medicare D to assist with medication copays.18 Patients may apply for this program anytime during the year and eligibility is determined by patient income. Lipid-lowering medications covered by Medicare B (inclisiran, evinacumab) would not apply for the Extra Help program.
Conclusion
Multiple lipid-lowering medications are now available to appropriately address atherogenic lipoproteins and reduce ASCVD risk; however, utilization of these medications may be limited by cost. Several resources are available to reduce medication costs and are outlined above. Depending on the type of prescription insurance, manufacturer coupons and patient assistance programs are available for nearly all branded lipid-lowering medications and can substantially reduce medication costs.
Dr. Ferarri has no financial relationships to disclose. Dr. Kelly has no financial relationships to disclose.
References:
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Khera R, Valero-Elizondo J, Das SR, et al. Cost-Related Medication Nonadherence in Adults With Atherosclerotic Cardiovascular Disease in the United States, 2013 to 2017. Circulation. 2019;140(25):2067-2075. doi:10.1161/CIRCULATIONAHA.119.041974
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Aggarwal R, Chiu N, Libby P, Boden WE, Bhatt DL. Low-Density Lipoprotein Cholesterol Levels in Adults With Coronary Artery Disease in the US, January 2015 to March 2020. JAMA. 2023;330(1):80-82. doi:10.1001/jama.2023.8646
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Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186] [published correction appears in Circulation. 2023 Aug 15;148(7):e5]. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625
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Writing Committee, Lloyd-Jones DM, Morris PB, et al. 2022 ACC Expert Consensus Decision Pathway on the Role of non-statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Solution Set Oversight Committee [published correction appears in J Am Coll Cardiol. 2023 Jan 3;81(1):104]. J Am Coll Cardiol. 2022;80(14):1366-1418. doi:10.1016/j.jacc.2022.07.006
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Hilas O. A Pharmacist’s Primer on Prescription Discount Cards. US Pharm. 2021;46(10):21-23.
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Guide to low cost prescriptions. Walmart Pharmacy Program. Updated April 15, 2023. Accessed May 11, 2024. https://i5.walmartimages.com/dfw/4ff9c6c9-e3f8/k2-_14c0785f-b2e4-4b2e-b1d6-97d32ca45d34.v1.pdf
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America’s Top Prescriptions for Less. Kroger Rx Savings Club. Accessed May 11, 2024. https://www.krogersc.com/static/files/KrogerRx-Program-Drugs.pdf
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Medications. CostPlus Drug Company. Accessed May 11, 2024. https://costplusdrugs.com/medications/
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RepathaⓇ (evolocumab) Co-Pay Card. AmgenⓇ SupportPlus. Accessed May 10, 2024. https://www.repathahcp.com/amgen-supportplus
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The Anti-Kickback Statute. 42 U.S. Code § 1320a–7b - Criminal penalties for acts involving Federal health care programs. 93rd Cong, 2nd Sess (1974).
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Commonwealth of Massachusetts. Mass. General Laws c.175H § 3: using prescription drug coupons. Accessed May 10, 2024. https://www.mass.gov/info-details/mass-general-laws-c175h-ss-3
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California Legislative Information. AB-265 Prescription drugs: prohibition on price discount. 2017. Accessed May 10, 2024. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB265
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LeqvioⓇ (inclisiran) Savings & Support. Novartis Pharmaceutical Program. Accessed May 11, 2024. https://www.leqvio.com/savings-and-support
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EvkeezaⓇ (evinacumab-dgnb) Patient Resources. myRAREⓇ Patient Support Program. Accessed May 11, 2024. https://www.evkeeza.com/s/patient-resources
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Centers for Medicare & Medicaid Services. Pharmaceutical Manufacturer Patient Assistance Program Information. Updated September 6, 2023. Accessed May 11, 2024. https://www.cms.gov/medicare/coverage/prescription-drug-coverage/patient-assistance-program
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Centers for Medicare & Medicaid Services. Costs in the coverage gap. Accessed May 10, 2024. https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverage-gap
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American Hospital Association. Fact Sheet: The 340B Pricing Program. Updated March 2023. Accessed May 11, 2024. https://www.aha.org/fact-sheets/fact-sheet-340b-drug-pricing-program
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Social Security Administration. Apply for Medicare Part D Extra Help program. Accessed May 11, 2024. https://www.ssa.gov/medicare/part-d-extra-help
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NexletolⓇ (bempedoic acid) Co-Pay Card. NexlizetⓇ & NexletolⓇ Co-Pay Savings Program. Accessed May 10, 2024. https://www.nexlizethcp.com/access-savings/
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Starting and Paying for PraluentⓇ (alirocumab). MyPraluentⓇ Copay Card. Accessed May 11, 2024. https://www.praluent.com/s/starting-and-paying-for-praluent-rx
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Starting and Paying for PraluentⓇ (alirocumab). MyPraluentⓇ Patient Assistant Program (PAP). Accessed May 11, 2024. https://www.praluent.com/s/starting-and-paying-for-praluent-rx#coverage
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Eligibility. AmgenⓇ Safety Net Foundation. Updated February 4, 2024. Accessed May 10, 2024. https://www.amgensafetynetfoundation.com/eligibility.html
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Novartis Patient Assistance Foundation. Novartis. Updated August 2023. Accessed May 11, 2024. https://www.novartis.com/us-en/patients-and-caregivers/patient-assistance/patient-assistance-foundation-enrollment
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EvkeezaⓇ (evinacumab-dgnb) Patient Resources. myRAREⓇ Patient Assistance Program (PAP). Accessed May 11, 2024. https://www.evkeezahcp.com/s/support-resources
Article By:
Assistant Professor (Clinical) - Department of Pharmacy Practice
Eugene Applebaum College of Pharmacy and Health Sciences
Wayne State University
Ambulatory Care Cardiology Pharmacist
Henry Ford Hospital
Detroit, MI
Associate Professor - Department of Pharmacy Practice
Thomas Jefferson College of Pharmacy
Philadelphia, PA