Presentation (CTI)

OBJECTIVES: To assess long-term trends in utilization, reimbursement, and pricing of ezetimibe and novel lipid-lowering medications (NLLMs) in Medicaid, including PCSK9, ANGPTL3 and ACL inhibitors.
METHODS: A retrospective descriptive trend analysis was conducted using CMS Medicaid State Drug Utilization Outpatient Pharmacy data files from 2002-2024. The analysis included ezetimibe (Zetia® and generic), and novel lipid-lowering medications: evolocumab (Repatha®), alirocumab (Praluent®), inclisiran (Leqvio®), bempedoic acid (Nexletol®), and evinacumab (Evkeeza®). Outcomes included quarterly prescription counts, total Medicaid spending, average reimbursement per prescription as a proxy of drug price, and market share competition.
RESULTS: Ezetimibe utilization increased rapidly following its 2002 approval, peaking at 281,374 prescriptions in Q4 2005, before declining by 85% by 2010, alongside reduced Medicaid spending. Utilization rebounded in the mid 2010s, reaching approximately 64,368 prescriptions per quarter, while average reimbursement per prescription increased from approximately $123 to $253. Following generic entry in Q4 2016, ezetimibe prescriptions increased by 7,273%, whereas brand Zetia utilization declined by 99.6% by Q4 2024. Utilization of NLLMs increased from 75 in Q4 2015 to approximately 64,600 prescriptions in Q4 2024, with total spending rising from $79,500 to $41.5 million. Average reimbursement per prescription declined by 45-50% for PCSK9 inhibitors, remained relatively stable for bempedoic acid, and was substantially higher for inclisiran and evinacumab. In Q4 2015, ezetimibe accounted for 99.88% of total utilization and 99.51% of spending. By Q4 2024, ezetimibe represented 78.84% of utilization but only 7.69% of spending ($3.459 million), whereas NLLMs accounted for 21.16% of utilization and 92.31% of Spending ($41.52 million).
CONCLUSIONS: Despite continued dominance of ezetimibe in prescription volume, Medicaid spending has shifted substantially toward high-cost NLLMs. These findings highlight a growing divergence between utilization and expenditure in Medicaid drug spending and underscore the importance of value-based pricing, outcomes-linked contracting, and formulary strategies as adoption of novel lipid-lowering agents expands.