Earnings Call Transcript - ESPR Q2 2021

Operator, Operator

Ladies and gentlemen, thank you for standing by and welcome. At this time, all participants are in a listen-only mode. Following the presentation, there will be a question-and-answer session. Please be advised that today's conference call may be recorded. I would now like to hand the conference over to Ben Church, Investor Relations and Corporate Communications at Esperion. Please go ahead, sir.

Ben Church, Investor Relations and Corporate Communications

Thank you, operator. Good morning and welcome to Esperion's Second Quarter 2021 Financial Results and Company Update Conference Call. I'm Ben Church, and I'm responsible for Investor Relations and Corporate Communications here at Esperion. I want to remind callers that the information discussed on the call today is covered under the Safe Harbor provisions of the Private Securities Litigation Reform Act. I caution listeners that management will be making forward-looking statements. Actual results could differ materially from those stated or implied by our forward-looking statements due to the risks and uncertainties associated with the business. These forward-looking statements are qualified in their entirety by the cautionary statements contained in today's press release and SEC filings. The content of this conference call contains time-sensitive information that is accurate only as of the date of this live broadcast, August 3rd, 2021. We undertake no obligation to revise or update any forward-looking statements to reflect events or circumstances after the date of this conference call and webcast. As a reminder, the conference call and webcast are being recorded and archived. We issued a press release this morning detailing the content of today's call. A copy can be found at www.esperion.com within the Investors & Media section. We will begin with prepared comments and then open the call for your questions. Following today's call, the team will be available for follow-up questions. Please email investorrelations@esperion.com to schedule a time to speak with our team. I'd now like to turn the call over to our President and CEO, Sheldon Koenig. Sheldon?

Sheldon Koenig, President and CEO

Thanks, Ben, and good morning, everyone. With me today for prepared remarks are Rick Bartram, Chief Financial Officer; and Dr. Joanne Foody, Esperion's new Chief Medical Officer. Also on the line is Eric Warren, our Vice President of US Sales and Marketing. I brought Eric on board in January to integrate and lead a unified sales and marketing organization. Eric, who is a pharmacist by training, has 25 years of commercial experience, focusing primarily on cardiometabolic and acute care medicine. He will be available for your questions at the end of this call as well. A special thanks to everyone joining us today for my first earnings call as President and CEO of Esperion. I'm excited to share with you all the great strides taken by Esperion over this past quarter to position ourselves for long-term success as a nimble, innovative organization solely focused on addressing cardiovascular disease, which remains the number one killer in the United States and worldwide. When I joined Esperion in December of last year, the company had recently launched the first oral non-statin LDL-C lowering medicine in nearly two decades, NEXLETOL and NEXLIZET. These are powerful first-in-class medicines with a novel mechanism of action and the potential to save patient lives. However, the commercial strategy was not yet maximizing the full potential of these medicines on top of the persisting COVID-19 pandemic headwinds. Having previously worked across many of the available LDL-C-lowering medicines, I have deep experience of what it takes to capture growth in the cardiovascular market and immediately recognized the untapped potential of NEXLETOL and NEXLIZET. Flash forward to today. We have now made many of the changes that were needed to strengthen our foundation and begin to recognize the potential of NEXLETOL and NEXLIZET. This includes bringing diverse experience to our senior leadership team, streamlining our commercial strategy, and implementing refined positioning for our medicines, all of which are moving this trajectory of NEXLETOL and NEXLIZET in the right direction. Our results from the second quarter show that these initiatives are already gaining momentum and materializing into growth. Prescribing physicians and prescriptions per physician are at their highest yet and continue to demonstrate a consistent double-digit and high single-digit growth respectively. In the quarter, NEXLETOL and NEXLIZET prescriptions grew 28% with accelerating month-over-month growth. But most importantly, our medicines have reached nearly 48,000 patients here in the US. Since the mid-April introduction of the revised product positioning, providers have expressed a clear understanding of where to prescribe NEXLETOL and NEXLIZET in patients that stand to gain the largest benefit. The revised NEXLETOL and NEXLIZET positioning has resonated with payers as well and has been beneficial in our new market access approach focused on improving the formulary status of our medicines, specifically among Medicare Part D payers. The success of these efforts is evident from the immediate response by Humana, adding both NEXLETOL and NEXLIZET to their formulary as of May 1st. We continue to have promising conversations with payers, who acknowledge the need for additional treatment options on formulary, to tackle the large patient population not yet at LDL-C goal. A strong priority for the team this quarter was maximizing the awareness and value of NEXLETOL and NEXLIZET and driving quality prescriptions. While our generous financial benefit co-pay programs supported patients and encouraged adoption of our medicines throughout the first year of launch and during the COVID-19 pandemic, we believe the second quarter was the appropriate time to adjust both the duration as well as the buy down magnitude of our co-pay card program to typical industry standards. With our strong commercial coverage in place, in an improved economic environment, these adjustments resulted in limited impact to patient access to our medicines. The volume of payer covered prescriptions improved, and second quarter net price was more favorable, contributing to the 67% sequential growth in U.S. net product revenue. We continue to expect additional positive impact to net pricing over time as plans fully implement coverage and volumes scale up. Since assuming the role of CEO, I've taken additional steps to position Esperion for long-term success, one of which is the addition of prominent cardiologist, Dr. Joanne Foody, as Chief Medical Officer. While our priority is steadfast on driving commercial excellence of NEXLETOL and NEXLIZET, ensuring we are prepared to capitalize on our unprecedented cardiovascular outcomes trial and the potential of our early-stage pipeline is vital. The importance of the CLEAR Outcomes study cannot be emphasized enough, not just for Esperion but for the entire field of cardiovascular medicine. Not only could our CLEAR Outcomes trial be monumental for encouraging late adopters, payers, and a broader application of NEXLETOL and NEXLIZET, but a potential risk reduction label indicates acceptance of an entirely new patient population that past medicines could not benefit. Historically, every LDL-cholesterol lowering therapy affecting the cholesterol synthesis pathway, as NEXLETOL and NEXLIZET do, demonstrated consistent outcome improvements. This, along with the unique and deliberate design of our CLEAR Outcomes trial, gives me great confidence in what is to come. All signs indicate that CLEAR Outcomes, now a little more than a year away, will make history in cardiovascular health and potentially further our leadership position in bringing innovation to underserved patients. If I could say only one thing, it would be this: Esperion is evolving quickly to maximize the opportunities that lie ahead and is instilling a laser-focused mentality on driving operational excellence throughout both the commercial side of the business and also in our clinical and development programs. I am proud of what this team has accomplished in such a short amount of time and continually gain confidence in the trajectory of Esperion and our future as a company. Now I'll turn the call over to Joanne to introduce herself and share with you all her motivation behind joining our team. Joanne?

Joanne Foody, Chief Medical Officer

Thank you, Sheldon, and good morning, everyone. I'm Dr. Joanne Foody, Chief Medical Officer and the newest member of the Esperion leadership team. I'm thrilled to join Esperion to strengthen its leadership team as we strive to provide lipid-lowering therapies to address the significant unmet need in heart disease. For the last three decades, as a preventive cardiologist, I have dedicated my career to improving outcomes for patients with, or at risk of cardiovascular disease. When the opportunity to lead Esperion as its Chief Medical Officer arose, I knew that this would be the right place to follow my passion to make a difference for patients. There is not one among us who has not had a family member or friend affected by heart disease or high cholesterol. These silent killers have taken loved ones far too early and far too often from me, as well as countless others, including most of you listening. Despite existing therapies, too many patients remain at risk due to high cholesterol. As the first new oral lipid-lowering therapy in two decades, bempedoic acid, either alone or in combination with ezetimibe, has the potential to transform patient care. During my time as a practicing cardiologist at the Cleveland Clinic and when on faculty at Yale and Harvard, I learned firsthand how physicians and patients are frustrated by the lack of tools available to address and stop the progression of heart disease. As I transitioned to industry, the lack of novel, accessible, and patient-friendly therapies to reduce cardiovascular risk became only more apparent. The need for therapeutic solutions in cardiovascular disease has, unfortunately, not changed despite statins or even injectable PCSK9 inhibitors. Recently, JAMA Cardiology published that only one-third of patients with atherosclerotic cardiovascular disease reach their cholesterol goals. That means that two out of every three high-risk patients did not achieve their goals and are at higher risk than they should be for heart disease. Esperion, the only company focused singularly on oral lipid-lowering solutions, is poised to tackle this problem head-on and transform clinical care with the CLEAR Outcomes trial. This is the largest cardiovascular outcomes trial to study patients not optimized on their statins or intolerant to statins. CLEAR Outcomes is unparalleled in its size, novel design, and unique patient population. This trial has taken into account all the lessons and insights of decades of cholesterol-lowering trials and is being run by teams of experts and chaired by Dr. Steven Nissen, an exceptional cardiologist and trialist. The trial's unique patient population and high starting baseline LDL cholesterol increases the likely probability of success. Further, given the unique mechanism of action of bempedoic acid and its known pleiotropic effects on inflammation and glucose, we anticipate the potential of additive benefits for patients. The thing is, I've been in cardiology for a long time. I've been involved in multiple global cardiovascular outcome trials across multiple big pharma companies. I've reviewed these trials as I wrote guidelines, but I have never seen a global trial of this quality, size, and scope being run at a company our size. That's a big deal. Our entire medical team is reenergized to bring NEXLETOL and NEXLIZET to all patients who can benefit from our indicated therapy today. And we are prepared to bring NEXLETOL and NEXLIZET to more patients who can potentially have outcomes benefit tomorrow. From the moment I started, I have been thoroughly impressed by the incredible talent and expertise of this team and their passionate commitment to bring back a sense of urgency to lipid management and cardiovascular risk reduction and advocate for continued innovation to ensure that patients and physicians have best-in-class, highly effective, convenient options to combat cholesterol. Thank you again for your time and attention. I cannot say it enough; there remains much work to be done, but I am confident that driven by science, we will demonstrate continued progress in this mission over the quarters ahead. Now Rick will provide comments on the quarterly financial performance.

Rick Bartram, Chief Financial Officer

Thanks, Joanne. Earlier today, we issued a press release containing our financial results for the second quarter, which is available on our investor website. US net product revenue was $10.6 million for the second quarter compared to approximately $600,000 generated in the second quarter of last year and $6.4 million in the first quarter of this year. Total revenue for the second quarter was approximately $41 million, which included $28.1 million in collaboration revenue related to the $30 million upfront payment received from our expanded partnership with Daiichi Sankyo that we announced in April. And there was approximately $1 million of royalty revenue from our European collaboration with Daiichi. Net price for our medicines improved during the second quarter as the commercial team implemented a number of changes to the co-pay card program, as Sheldon highlighted earlier. Over time, we expect our net price to continue to improve as plans fully implement coverage and volumes scale up. On expenses, R&D expense for the second quarter approximated $25 million, down 10% from the first quarter. SG&A expense was approximately $46 million for the second quarter, down 24% from the first quarter. The sequential decline in SG&A expense was driven predominantly by a one-time charge associated with a legal settlement in the first quarter. We continue to expect our full year 2021 R&D expenses to fall between $120 million to $130 million and SG&A expenses to be between $200 million and $210 million. Note that these amounts are inclusive of approximately $30 million in noncash stock-based compensation expense for the full year. Our cash balance as of June 30 was approximately $219 million. We remain committed to prudently managing expenses and will ensure the organization is adequately funded to advance the business. Going forward, you should expect us to continue to balance cash spending against growth potential and the cash needs to ensure the business is resourced for future growth. Before handing the call back to Sheldon, let me summarize our financial progress. First, we had 67% quarterly growth of NEXLETOL and NEXLIZET net revenue; second, we saw improved net price of our medicines through the adjustments of our co-pay card program highlighted earlier; and lastly, we remain extremely diligent in managing our cash while supporting the commercial launch and our CLEAR Outcomes trial. By maintaining this focus, we are confident our financial position will continue to strengthen throughout the remainder of the year. With that, I will turn it back to Sheldon for closing remarks.

Sheldon Koenig, President and CEO

Thanks, Rick. I want to say again how proud I am of what the team has accomplished and the direction Esperion is headed in. While there is still a lot of work left to do, we continue to drive a sense of urgency across the organization to bring value to our shareholders, healthcare providers, and most importantly patients. Our refined commercial strategy has begun to demonstrate traction across a number of fronts translating to expanded Medicare Part D coverage, substantial prescription growth of NEXLETOL and NEXLIZET, and other key commercial metrics including net pricing. While we continue to work towards operational excellence, we remain steadfast on the true mission at heart: an opportunity to transform the lives of millions of patients struggling to lower their LDL cholesterol. A big thank you to all our colleagues and partners for their hard work, passion, and commitment this quarter and every quarter. And again, thank you all for joining today and your continued support and interest in Esperion. Operator, we are now ready for Q&A.

Operator, Operator

Our first question comes from Michael Yee from Jefferies. Your line is now open.

Michael Yee, Analyst

Hi everyone, good morning. Thank you for taking my question. I have two inquiries. First, you mentioned that gross to net is expected to improve, which is great to hear. Could you provide some quantification on that? In 2020, it seemed to be around 35 to 40 percent, but it dropped significantly in the first quarter. Do you anticipate the rest of the year to be closer to 50 percent? Is that a reasonable range? Please share your thoughts on that. Secondly, regarding the broader situation, we know that COVID has affected operations in recent quarters, though things have improved significantly. Could you comment on the current environment and whether you feel patient volumes are improving? Thank you.

Sheldon Koenig, President and CEO

Good morning. Thank you, Michael. This is Sheldon. Let me first address your question about gross to net. I want to highlight that we have observed a significant improvement in our net price, as you pointed out. This is something we've consistently communicated since last quarter and we are committed to continuing this effort. The team has done an excellent job in a short period of time, and we believe this improvement will persist into the third quarter and beyond. While I can't share specific percentages or details regarding our gross to net figures, I want to emphasize our dedication to reducing our exposure and ensuring quality prescriptions. Our demand increased by 28%, and I’m optimistic about further improvements as we move into the third and fourth quarters. Regarding COVID, we are monitoring the situation with the Delta variant closely. Our representatives have remained active in the field since the onset of the pandemic in March 2020, and feedback indicates that more individuals are returning to the office and that physicians are seeing more patients. Vaccination rates are also rising as people recognize the importance of getting vaccinated, especially with the current variant. Slowly, things are returning to normal. I will now ask Eric Warren if he has any additional comments.

Eric Warren, Vice President of US Sales and Marketing

Thanks, Sheldon. Nice to meet you, Michael. My name is Eric, as Sheldon mentioned. I have responsibility for our sales and marketing teams at Esperion. I'm a pharmacist by training, with 25 years in the industry, and most of my experience has been in cardiometabolic disease. I came here just a few months ago. And really, three reasons behind that: the people here have been incredible; the medicines have been inspirational; and the clear focus on cardiovascular disease is to be complemented. So with regards to the sales force activity, we've seen a significant increase in the number of calls per day that our team has been able to make. They're seeing more targeted customers, and they're able to increase their frequency on customers. We've also seen a really significant increase in the number of peer-to-peer programs from Q1 to Q2, so all those are good signs from a COVID perspective. Now, yes, the Delta variant is on our minds. We're keeping a close eye on that. We can't predict where it will pop up and where it will go down. But we are making sure that our teams are armed with the proper safety equipment and masks have always been a mandate, as they are with our HCP offices. And we're really committed to making sure that our team is out there, communicating the benefits and risks of our compounds and ensuring that appropriate patients receive our product.

Michael Yee, Analyst

Thank you.

Operator, Operator

Thank you. Our next question comes from the line of Joseph Thome from Cowen and Company. Your line is now open.

Joseph Thome, Analyst

Good morning. I appreciate your willingness to answer my questions. To start, I understand that you are focusing on the high-volume prescribers. Can you discuss the balance between specialty cardiology practices and primary care physicians, and where you're observing the higher rates of prescribing? Additionally, for those doctors who are not yet adopting the therapy, what do they need to see? Are they looking for cardiovascular outcome data, or is there other information you think could encourage them to adopt the therapy sooner? Thank you.

Sheldon Koenig, President and CEO

Great. Thanks, Joe. Our microphone is a little jumbled here, but I think I got the first part of your question. And that is, who do we really see prescribing NEXLETOL and NEXLIZET? What's that breakout between primary care and cardiologists? What we're seeing is that there's more primary care physicians that are writing both NEXLETOL and NEXLIZET than cardiologists. That's probably closer to a 60% to 40% split; 60% primary care, 40% cardiology. This is not unexpected. This is, as you may or may not be aware, I ran the brand of Zetia Vytorin while I was at Merck, and we saw that the majority of prescribing of ezetimibe was in primary care. We're starting to see the same here as well as it relates to NEXLIZET and NEXLETOL. The second part of your question is, what else do they need to see? Sorry, yes. So, actually, for us, one of the things that we mentioned last quarter was awareness. We're starting to see awareness of these brands improving. The CLEAR Outcomes study, which I will have Joanne comment briefly on in just a second, is definitely something that's going to be very important for us. But again, looking at other products and analogies, there's a lot of patients; close to 18 million patients in the United States who have a lipid abnormality, are not achieving their LDL-C goal and they need treatment now. Our physicians realize this and they don't want a delay in trying to get their patients to their LDL target. So we believe we have a lot of room to grow. As we mentioned in the script, we have 48,000 patients currently on these drugs. I mentioned the number of 18 million. As my partner here, Eric Warren would say, we're just scratching the surface. And we think that we can again really grow and have an inflection point; the CLEAR study, as I've always said, will provide us maybe a secondary inflection point. Joanne, any color you'd want to add on the CLEAR Outcomes study?

Joanne Foody, Chief Medical Officer

Thank you, Sheldon. And thank you, Joseph, for your question. I think as Sheldon mentioned, the CLEAR Outcomes trial will be an important inflection point. However, over the next 15 months as we anticipate that study close, we have developed a very significant integrated evidence approach that will leverage real-world data to provide information for providers, clinicians, and ordinary payers with respect to our value proposition. And so, as Sheldon mentioned, there is a significant amount of work that will be ongoing to refine our understanding of treatment gaps, patient phenotypes, those who might be most likely to benefit today from our therapy, and ultimately do this all to have solid grounds for the CVOT. What you may not be aware of is, as an Outcomes researcher in my academic career for many years and having reasonably been Head of Data Science for Johnson & Johnson in the cardiovascular space, most of that work was really on how we could leverage big data, how we could leverage electronic health records, and all the data that exist in the real world to help providers understand the value. And all this ultimately drives our commercial utilization. So, as Sheldon mentioned, I think right now we want to continue to work to improve patient identification, improve understanding and awareness of those patients most likely to benefit from NEXLETOL and NEXLIZET today, while we anticipate the data generated from the CV Outcomes trial in the future.

Joseph Thome, Analyst

Great. Thank you.

Operator, Operator

Thank you. Our next question comes from the line of Chad Messer from Needham & Company. Your line is now open.

Chad Messer, Analyst

Great. Thanks. Thanks for taking my question. You talked a little bit about in mid-April revising your product positioning. Just wondering if you could talk a little bit to how that has affected sort of the patients that are using the drugs. So even anecdotally, as you talk to the physicians, what patients would be using your drug and maybe how it changed with the new positioning?

Sheldon Koenig, President and CEO

Yes. So, thanks Chad for the question. Let me just start off quickly. One of the things that we introduced was the new positioning in April. One of our bellwethers testing to say is this the right positioning was the win that we had with Humana, which is one of the largest Medicare Part D providers with close to 9 million patients. It was obvious that the position was clear and understood. We had a quick turnaround concerning an answer from Humana. I'm going to ask Eric to comment on what he's seeing in the field. He's the one who's been deploying this positioning and working closely with the field. Eric?

Eric Warren, Vice President of US Sales and Marketing

Great. Hi, Chad, nice to meet you. So yes, we deployed some revised positioning in April. The goal was to hone in on a specific patient type where our success would be evident. Rather than talking about five or six patient types that may not stick with our clinicians, we really drove into one where we knew and that we saw success. The population again that we focused on is consistent with our indication: ASCVD and HeFH patients that aren't at goal, they're on other therapies, and statin therapy they've maxed that out. There is an intention to do more for the patient. That's where NEXLETOL and NEXLIZET come into play. It's a sizable population and gives the opportunity to demonstrate the efficacy as well as the safety profile of the compound, creating a base for us to expand. We've got two phases of expansion planned: a phase that happens before CVOT and then a phase that happens after CVOT. As Sheldon mentioned, from a payer perspective, that strategy is resonating well. From a practitioner perspective, it's been resonating well, and also from an internal perspective, I think our sales team appreciates the clarity that we've provided.

Chad Messer, Analyst

Okay. Great. I appreciate that. Is it fair to say based on your guys' experience that the idea of statin intolerance just hasn't gained the traction we once all thought it might?

Sheldon Koenig, President and CEO

Let me speak to that. Statin intolerance is something that's been ongoing since statins have been launched. More so I think after lovastatin and going into ZOCOR, there's always been a thought that there's a rate of anywhere between 16% and 20% of all patients who are statin intolerant. That doesn't mean they can't take a statin at all. It means that they can only take maybe even a certain dose of statin. So this isn't really about just that intolerance, but it's really about patients achieving LDL goal. The treatment paradigm has become a step-guided treatment. I'm not a physician; Joanne is, but I'll just make this comment: it evolved from a statin to then a statin plus ezetimibe, and now it's a statin plus ezetimibe and something else. We believe that something else is NEXLIZET and NEXLETOL pre-CVOT. As I mentioned, there are millions of patients who are taking statins and statins and ezetimibe and are still not at LDL goal. And as we mentioned earlier, cardiovascular disease is the number one killer. So there's definitely a place for NEXLIZET and NEXLETOL. Again, we've seen that in this quarter. We had 67% growth in revenue; we had 28% growth in demand. We're calling these quality prescriptions. Again, I think there's a lot of potential for these brands.

Joanne Foody, Chief Medical Officer

Sheldon, I just want to add that from a physician's viewpoint, specifically as a cardiologist, I believe statin intolerance is real. The issue is that it's often not recognized because patients have endured muscle symptoms due to the lack of available therapies. So, in line with your comment, some of this has not been fully utilized, but we now have NEXLETOL and NEXLIZET, which can address these concerns. It's important to acknowledge that statins have been the main oral therapy available, and many people suffer as a result. We have a chance to expand our reach. Additionally, as Sheldon pointed out, it’s not only about statin intolerance; there's also the issue of statin hesitancy, where individuals choose not to take any therapy, thus leaving their cardiovascular risk elevated. Moreover, there's also a lack of optimization with statins, where patients may be prescribed lower doses than necessary to effectively lower their cardiovascular risk. Many patients are unable to take the optimal statin dose for various reasons. We believe this is where NEXLETOL and NEXLIZET can make a significant impact.

Chad Messer, Analyst

Great. Thanks. Appreciate it.

Operator, Operator

Our next question comes from the line of Jason Butler from JMP Securities. Your line is now open.

Jason Butler, Analyst

Hi. Thanks for taking my question. First one with the focus on high-quality prescriptions, are you continuing to evaluate sales force sizing and territory prioritization? And then secondly, can you just give us an update on the launch in Europe and how that's progressing?

Sheldon Koenig, President and CEO

Sure. Great. Thank you, Jason. So as it relates to the sales force size, we believe that we have the right sales force and size. I'm going to ask Eric to comment in a bit, but let me just first talk about Europe. So in Europe, we continued to see strong performance from Daiichi Sankyo. They launched both of these products in October of 2020 and have continued to see growth. They're currently launched in Germany. They're also launching in the UK and a handful of other smaller countries. We meet with them on a weekly basis. We have a great partnership with Daiichi Sankyo, and again, performance is doing quite well there. Eric, do you want to talk about how we evaluate sales force size?

Eric Warren, Vice President of US Sales and Marketing

Sure. Sure, absolutely. Nice to meet you, Jason. So right now, our sales force is approximately 200 territory managers. It's been stable through Q2, which is a good sign, and I do think it is right-sized to support the near-term opportunity. However, to reach the maximum potential, there are a lot of customers, specifically primary care physicians, that we intend to be able to cover. We're constantly evaluating appropriate ways to reach these practitioners. But we have to do so, obviously, in a cost-effective manner.

Jason Butler, Analyst

Great. Thanks for taking the questions.

Operator, Operator

Thank you. Our next question comes from the line of Tom Shrader from BTIG. Your line is now open.

Tom Shrader, Analyst

Good morning. I'm getting long patches of silence. I can't tell if it's me or the general call, but I wanted to re-ask a piece of Chad's question. Is the majority or the vast majority of your users now people already on ezetimibe?

Sheldon Koenig, President and CEO

Hey, Tom. First of all, we're not receiving reports. It might be due to your connection. Last quarter, we experienced some issues, and people informed us right away. But we're not getting those reports now. I just wanted to mention that. If others are having the same issue, please contact the operator. We chose the new room specifically to avoid that this time. Regarding patients currently using NEXLIZET and NEXLETOL, we have a good mix of patients on statins and those on statins and ezetimibe using both products. Our current focus, as we mentioned, is on patients taking a statin plus ezetimibe. We believe there is potential to utilize NEXLIZET and NEXLETOL before considering an injectable PCSK9. Some doctors only prescribe statins but have added NEXLETOL or NEXLIZET. The usage of NEXLETOL and NEXLIZET is roughly equal, with about 50-50 in the distribution of both drugs.

Tom Shrader, Analyst

All right. And then just one housekeeping question. Are the co-pay cards greater than three months? Are they completely gone? And did they have any impact this last quarter?

Sheldon Koenig, President and CEO

Yeah. So, I'll have Eric comment on the co-pay cards.

Eric Warren, Vice President of US Sales and Marketing

Sure. Hi, Tom, nice to meet you. As Sheldon mentioned earlier, profitable growth is really important to us. Yes, in the past we've leveraged co-pay cards for multiple purposes, not only to lower the out-of-pocket cost that a patient pays for an approved or a commercial patient pays for an approved script, but also to create a bridge, if you will, for those patients that are awaiting prior authorization approval. The co-pay card will continue to last for an extended time for those patients that are commercially approved, and we are paying down the prescription to make it more affordable. However, we've made some changes to the co-pay card, and will no longer be creating that bridge, if you will, to cover those patients that are awaiting their prior authorization. Instead, we've implemented additional programs, including something requiring the prescription support program to support those patients.

Tom Shrader, Analyst

Got it. Thank you.

Operator, Operator

Thank you. Our next question comes from the line of Geoff Meacham from Bank of America. Your line is now open.

Olivia Brayer, Analyst

Hi, guys. This is Olivia Brayer. Thanks for the questions. Sheldon, can you give us an update on where you are in conversations with payers on the Medicare coverage side? I know you've been added by Humana, and that obviously took some time to play out. So how do you think about timelines for getting added to other major formularies and whether that's something that could realistically play out this year? And then I have one follow-up after that.

Sheldon Koenig, President and CEO

Okay. So first of all, thanks for your question. Again, just to reiterate, we're really happy about the win with Humana. I know I mentioned it a lot, but that was a big win for us; again the largest Medicare Part D provider, and a good test of our positioning. As it relates to the contracting where we are today, so we're currently in talks with other providers. I think it's important to note though that while we're also in talks with other providers, we can still do pull-through of both contracted and non-contracted accounts. That is something that we are really concentrating on and focusing on driving demand while we have those discussions. We're happy where we sit today as it relates to our commercial coverage with greater than 90% and our Medicare coverage is 60%. We'll continue to update you as we go through the third and fourth quarters. I'm not going to comment on when we actually think we would have contracts; we want to make sure that whatever we do is thought-out, makes sense and, in the meantime, still be able to drive demand, which we are able to do. And Olivia, your follow-up?

Olivia Brayer, Analyst

Yeah. And then my second question is really around opportunities for partnerships beyond what you've already been able to establish. I know you guys have talked about China and other geographies that could help drive growth over the longer term. But are there certain countries that are maybe more of a priority at this point or more of a near-term focus than others?

Sheldon Koenig, President and CEO

Yeah. So first, again, I want to reiterate as you know we have an agreement with Daiichi Sankyo for Europe. We expanded that agreement with the Asia region. So that allowed for a partnership in different markets, not only in Asia but some also in Latin America. China and Canada are two that still stand out that we have complete ownership of. I think the best way to think about this is our focus really is on the US. Right now we're focusing on the US and continuing to drive performance and growth of NEXLETOL and NEXLIZET. That's where we will be spending the majority of our focus as we move throughout this year.

Olivia Brayer, Analyst

Okay, great. Thank you.

Sheldon Koenig, President and CEO

Sure.

Operator, Operator

Thank you. Our next question comes from the line of Jeff Hung from Morgan Stanley. Your line is now open.

Jeff Hung, Analyst

Thanks for taking the questions. You've talked about addressing the co-pay card and then in the past the need for greater touch points with physicians to generate written scripts. What additional levers do you have to impact the trajectory of scripts?

Sheldon Koenig, President and CEO

Hi, Jeff. I'm actually going to have Eric speak to that. Eric?

Eric Warren, Vice President of US Sales and Marketing

Thanks, Sheldon, and nice to meet you as well, Jeff. Yes, obviously, scripts come from awareness of our compounds. So being able to have live interactions is critical. As I mentioned, we've been able to increase the number of direct engagements we've had with our customers and not only our customers but our targeted HCPs, which is really important. We've had a double-digit improvement from Q1 to Q2 in terms of our reach. We've seen increased frequency. I've also mentioned that we've improved our ability to reach our customers from a peer-to-peer perspective. We had a significant bolus of activity in June, not only smaller programs of about 10 in size, but we did two national programs where we're able to engage more than 1000 HCPs in peer-to-peer activity. So that's important to us, and we see that as a mechanism to drive scripts. In addition, I mentioned the prescription support program is going to be critical. Obviously, with prior authorizations for some plans, it's important that our customers are prepared to be able to complete those to maintain timely access. As I mentioned, August 1, we have implemented this prescription support program. This program includes a dedicated support team that works both with the patient as well as the office to ensure that all the proper documentation is processed and that the prior authorization is approved.

Jeff Hung, Analyst

Thanks. And then, you've indicated that Esperion could only reach about half of the physicians it needed to cover in June. How has the ratio of reached versus targeted physicians changed over the last few months?

Eric Warren, Vice President of US Sales and Marketing

Yeah. So we've actually been able to reach more than half of our targeted HCPs. We're closer to two-thirds of those targeted HCPs.

Jeff Hung, Analyst

I was just curious how that's changed over the last few months.

Eric Warren, Vice President of US Sales and Marketing

Yeah, it's improved. We're seeing significant improvements in our ability to get to our targeted customers. That is a testament to the sales force and their passion and dedication out there. They've been out there consistently throughout the COVID time if you will. They've seen significant improvements now because of their persistence and the quality of the compounds that we have.

Sheldon Koenig, President and CEO

I would also add, Eric, I think just the introduction of data analytics and how you've applied analytics to really territory targeting and performance measurement has also been key in doing that.

Jeff Hung, Analyst

Okay. Thank you.

Operator, Operator

Thank you. Our next question comes from the line of Jessica Fye from JPMorgan. Your line is now open.

Jessica Fye, Analyst

Hey guys. Good morning. Thanks for taking my question. First question is, can you talk about how the franchise is doing in Europe? Maybe translate what the royalty revenue means for overall sales in Europe, so we can get a sense of how the business is doing there?

Sheldon Koenig, President and CEO

Hi, Jess. Let me first say that Europe has been performing well. Our partners at Daiichi Sankyo, as I mentioned earlier, they continue to see growth in the number of patients on a monthly basis. I'll have Rick comment on, as it relates to royalty aspects.

Rick Bartram, Chief Financial Officer

Yeah. Thanks, Jess. We did communicate that we had about $1 million of royalty revenue from the European collaboration. That collaboration is available publicly. We're not commenting on the actual revenue dollars. You can do calculations, but given some of the exchange rates, we're not commenting on that.

Jessica Fye, Analyst

Okay. And the next one is just on the cash runway, either for Sheldon or Rick. I think Sheldon, in the prepared remarks, you mentioned the CLEAR Outcomes data is a little over a year away. So is it your expectation that you have the cash to get to that data readout? And can you talk about strategies you might use to top off the balance sheet so you get to that CLEAR Outcomes data with a little cushion?

Rick Bartram, Chief Financial Officer

Yeah. Thanks, Jess. Yes. So as we mentioned in the prepared remarks, and as you saw in the press release, we had about $220 million in cash. When we look at the business and we look at the cash available to us, I just want to point out and reiterate we have about $1.2 billion of future milestones. We do expect those to continue to feed our balance sheet over time. We're constantly evaluating cash runway, looking for ways to not only optimize costs in our expenses, but just be thoughtful about how we bring additional capital into the organization. As you know, we capitalized on two non-dilutive funding sources this past quarter, the expansion with Daiichi under that partnership and then with our financial partners, Oberland Capital. We're going to continue to have that mindset, evaluate options, and just make sure that the business is funded to deliver the business plan and grow our products.

Jessica Fye, Analyst

Okay, great. And then, just lastly on the progress of CLEAR Outcomes, as we try to think about maybe when in the second part of 2022 that could come, is there any next communication that we should be anticipating from you guys on maybe the proportion of events that have occurred? Just anything we should be kind of watching for on progress updates there?

Sheldon Koenig, President and CEO

Let me have Joanne provide some insight on that. Currently, we are at 75%. Joanne, would you like to add anything?

Joanne Foody, Chief Medical Officer

Thank you, Jess, for the question, and clearly just to first say that the CLEAR Outcomes study is currently on track to execute and close out at the end of 2022. Importantly, we have accumulated 75% of our MACE events. It's important for people to recognize. I think there's a lot of concern about COVID. But remember again that the study was fully enrolled prior to COVID in 2019 and has not seen any impact from COVID. We will continue to report out the accumulation of MACE events next year, and otherwise the study is fully on track. When we compare the study to other studies and historical benchmarks, we are in a good place to execute on this study.

Operator, Operator

Thank you. Our next question comes from the line of Paul Choi from Goldman Sachs. Your line is now open.

Charlie Ferranti, Analyst

Hi everyone. Thank you so much for taking the question. This is Charlie on for Paul. I think just one from us at this point regarding adjustments that have been made to improve the net price as the launch continues. Can you give us a sense of the timing of those adjustments throughout the quarter? Does the entire quarterly revenue reflect those adjustments, or was that something that kind of arose as time went on throughout the quarter such that maybe only a portion or half of the quarter really reflects the improvement in that price? Thank you so much.

Sheldon Koenig, President and CEO

Thanks, Charlie. So as it relates to the improvement, it was something that was done over a couple of months honestly. Still, as I mentioned earlier and in our prepared remarks, we still see further improvement that can be attained as we move into the third and fourth quarters. Again, this is something that we are looking at very diligently. The fact that we could say that we had a notable improvement in net price in such a short amount of time was very important for us. It was something that we set out to do. We said we would do it, and we're going to continue to do it as each and every day goes by wherever we can look for those types of efficiencies.

Charlie Ferranti, Analyst

Got it. Sounds good. Thank you so much for taking that question.

Operator, Operator

Thank you. This concludes today's conference call. Thank you for participating. You may now disconnect.