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Wisconsin medicaid's prior authorization guidelines for brand name hmg-coa reductase inhibitors, focusing on the use of generic lovastatin to reduce costs. Information on the cost comparison between brand name and generic lovastatin, the clinical information on hmg-coa reductase inhibitors, and recommendations for prescribing and monitoring. The document aims to help prescribing physicians and pharmacies understand the guidelines and save costs for the medicaid program.
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To: Prescribing Physicians, Pharmacies From: Wisconsin Medicaid, Division of Health Care Financing January 2004
In order to encourage the use of generic lovastatin, the Wis- consin Medicaid program began requiring prior authorization for brand name HMG-CoA reductase inhibitors on April 15,
For more information, go to the Wisconsin Medicaid phar- macy handbook website at http://www.dhfs.state.wi.us/Medicaid2/handbooks/pharmac y/index.htm.
Wisconsin Medicaid analyzes claim data to review adherence to prior authorization policies.
THE COST OF GENERIC VERSUS BRAND- NAME HMG -COA REDUCTASE INHIBITORS
In June 2002, lovastatin became the first HMG-CoA reduc- tase inhibitor with an AB rated generic equivalent. All other statins are currently available only as brand name products. Brand name lovastatin is also still marketed as Mevacor. Other brand name products include Altocor (lovastatin ER), Lipitor
(atorvastatin), Zocor (simvastatin), Pravachol (pravastatin), Crestor (rosuvastatin), Lescol (fluvastatin), and Lescol XL (fluvastatin XL). Products that contain an HMG-CoA reductase inhibitor combined with another ingredient (e.g. Advicor) were not included in this analysis. The generic form of lovastatin is significantly less expen- sive to the Medicaid program than brand name products. Average cost to the Wisconsin Medicaid Program for generic lovastatin 40 mg is $1.20 per tablet^1 and for a brand name HMG-CoA reductase inhibitors (including the brand name forms of lovastatin) range from $1.65 to $4.18 per equipotent dosage^2 (table 1).
Trade Name Generic Name Cost Per Tablet
Mevacor 40 mg Lovastatin $4.
Zocor 20 mg Simvastatin $4. Pravachol 40 mg Pravastatin $3.
Crestor 10 mg Rosuvastatin $2.
Lipitor 10mg Atorvastatin $2. Lescol 40 mg or Lescol XL 80 mg
Fluvastatin or Fluvastatin XL
Altocor 40 mg Lovastatin ER $1. Lovastatin 40 mg (Generic)
Table I Cost Per Tablet for Wisconsin Medicaid
The annual drug budget for the Wisconsin Medicaid program is currently over $500 million. The budget has increased approxi- mately 16 percent each year over the past 2 years. Wisconsin Medicaid spent more than $12.5 million on HMG-CoA reductase inhibitors in 2001. In 2002, Wisconsin Medicaid spent more than $16 million. This is an increase of 29% from the previous year. The average cost per prescription of an HMG-CoA reductase inhibitor for the last quarter of 2002 as compared to the cur- rent cost per prescription is illustrated in Figure 1. The percent of the overall number of prescriptions for these agents is illus- trated in Figure 2. Figure 1 A v e r a g e C o s t P e r S t a t i n P r e s c r i p t i o n f o r t h e Wisconsin Medicaid Program
$
$
$ $
$
$ $
$104 $ $
$ 0
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$
$
$
$
$
Lovastatin Fluvastatin Pravastatin Simvastatin Atorvastatin
Quarter 4 2002 Current
Figure 2 P e r c e n t M a r k e t S h a r e o f H M G - C o A R e d u c e s Inhibitors Prescriptions for the Wisconsin Medicaid Program
2.9% (^) 4.4%
10.6%
58.4%
23.8%
3.7% 10.0%
56.4%
22.5% 7.5%
0%
10%
20%
30%
40%
50%
60%
70%
Lovastatin Fluvastatin Pravastatin Simvastatin Atorvastatin Quarter 4 2002 Current
HMG-CoA reductase inhibitors (also known as ‘statins’) are used to treat dyslipidemias of various etiologies. Table 2 briefly su mma- rizes the approved indications of the available products.
When given in approximately equivalent daily doses, HMG-CoA reductase inhibitors can reduce low-density lipoprotein (LDL) cholesterol up to about 40% (table 3). However, if a reduction in LDL greater than 40% is desired, a daily dose of atorvastatin 20mg, lovastatin 80mg, simvastatin 40mg or rosuvastatin 5 mg is more likely to achieve this goal.
In addition to the reduction of LDLs, the HMG-CoA reductase inhibitors have mixed influence on other lipoproteins. Even though this article concentrates on the reduction of LDLs, table 4 briefly summarizes which HMG-CoA reductase inhibitors are approved to treat other lipoprotein disorders.
Atorvastatin Fluvastatin Lovastatin Pravastatin Simvastatin Rosuvastatin Hypercholesterolemia X X X X X X Mixed Dyslipidemia X X X X X Primary Prevention Of CHD X X X X X Secondary Prevention Of CHD X X X X Dysbetalipoproteinemia X X X Elevated Serum Triglycerides X X X X
Rosuvastatin 5 (45%) 10-20 (52-55%) 40 (63%) Atorvastatin 10 (38%) 20 (43%) 40 (50%) 80 (60%) Simvastatin 10 (30%) 20 (38%) 40 (41%) 80 (47%) Lovastatin 10 (21%) 20 (27%) 40 (31%) 80 (42%)--as 40 bid Pravastatin 20 (30%) 40 (34%) Fluvastatin 20 (20%) 40 (24%) 80 (30%) Fluvastatin XL Lovastatin ER
Baseline LDL in mg/dL
Goal LDL of <100 mg/ dL 100 1.00% Goal LDL of <130 mg/ dL
110 10.00% 120 17.50% 0.00% (^130) 23.85% 0.77% 140 29.29% 7.86% Goal LDL of <160 mg/ dL
150 34.00% 14.00%
160 38.13%^ 19.38%^ 0.63% (^170) 41.76% 24.12% 6.47% 180 45.00% 28.33% (^) 11.67% 190 47.89% 32.11% 16.32% 200 50.50% 35.50% 20.50% 210 52.86% (^) 38.57% 24.29% 220 55.00% 41.36% 27.73% (^230) 56.96% 43.91% 30.87% 240 58.75% (^) 46.25% 33.75% 250 60.40% 48.40% 36.40% 260 61.92% 50.38% 38.85% 270 63.33% 52.22% 41.11% (^280) 64.64% 53.93% 43.21% 290 65.86% (^) 55.52% 45.17% 300 67.00% 57.00% (^) 47.00% 310 68.06% 58.39% 48.71% 320 69.06% 59.69% 50.31% 330 70.00% 60.91% 51.82% 340 70.88% 62.06% 53.24% 350 71.71% 63.14% 54.57% 360 72.50% (^) 64.17% 55.83% 370 73.24% 65.14% 57.03% 380 73.95% 66.05% 58.16%
APPROXIMATE (%) REDUCTION IN LDLs AND COST PER MONTH OF THERAPY
Fluvastatin 10mg QD (20%) $48.97/month Lovastatin 10mg QD (21%) $12.83/month
Lovastatin 20mg QD (27%) $20.63/month Fluvastatin 40mg QD (24%) $48.97/month Fluvastatin 40mg BID (30%) $97.94/month Fluvastatin XL 80mg (30%) $62.73/month Pravastatin 20mg QD (30% $81.32/month Simvastatin 10mg QD (30%) $69.39/month
Lovastatin 40mg QD (31%) $36.23/month Pravastatin 40mg or 80mg QD (34-37%) $119.34/month Simvastatin 20mg QD (38%) $121.05/month Atorvastatin 10mg QD (38%) $66.88/month
Simvastatin 40mg QD (41%) $121.05/month Lovastatin 40mg BID (42%) $72.90/month Atorvastatin 20mg QD (43%) $98.60/month Rosuvastatin 5mg QD (45%) $69.30/month
Simvastatin 80mg QD (47%) $121.05/month Atorvastatin 40mg QD (50%) $96.19/month Rosuvastatin 10mg or 20mg QD (52-55%) $69.30/month
Atorvastatin 80mg QD (60%) $96.19/month Rosuvastatin 40mg QD (63%) $69.30/month
=LDL reduction not likely with HMG-CoA reductase inhibitor mono- therapy