Changes of ticagrelor formulary tiers in the USA: targeting private insurance providers away from government-funded plans.

CONTEXT: Ticagrelor (Brilinta®) is a new oral reversible antiplatelet agent approved by the FDA in July 2011 based on the results of the PLATO (Platelet Inhibition and Patient Outcomes) trial. However, despite very favorable and broad indications, the current clinical utilization of ticagrelor is woefully small.

OBJECTIVE: We aimed to compare ticagrelor formulary tiers for major private (n = 8) and government-funded (n = 4) insurance providers for 2012-2013.

RESULTS: Over the last year, ticagrelor placement improved, becoming a preferred drug (from Tier 3 in 2012 to Tier 2 in 2013) for Medco, moving from Tier 4 (with a prior approval requirement) to Tier 3 (no prior approval) for the United Health Care Private Plan and achieving Tier 3 status for Apex in 2013. In contrast, ticagrelor placement did not improve for New York Medicaid, retaining Tier 3 status. In addition, many Medicare Part D formularies have significantly worse coverage than most private plans. For example, Humana Medicare Part D has Tier 3 status requiring step therapy and quantity limits, SilverScript (CVS Caremark) Part D is Tier 3 and the American Association of Retired Persons (United Health Care) Medicare Part D is Tier 4 requiring prior approval.

CONCLUSIONS: Ticagrelor formulary placement is significantly better for most private providers than for government-funded plans, which may possibly be due to the selective targeting of private insurance providers and the simultaneous avoidance of government-funded plans.