The Alliance for Patient Access / What's New / ***PRESS RELEASE*** Florida Health Plans Reject Nearly Half of Claims for High Cholesterol Treatment

***PRESS RELEASE*** Florida Health Plans Reject Nearly Half of Claims for High Cholesterol Treatment

New health plan report card analyzes PCSK9 inhibitor claims for managed care organizations.

WASHINGTON – The Institute for Patient Access today released a new Health Plan Coverage Report Card highlighting the rates at which Florida insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject nearly one out of every two claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from August 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims for Florida managed care organizations, including commercial plans, Medicare and managed Medicaid.

Key Florida Findings:

  • 45% average rejection rate
  • 3,784 total rejections
  • 1,197 appeals
  • Highest rates of rejection: Federal Employee Benefit Plan (77%), Express Scripts (76%), Cigna Healthcare (63%)
  • Lowest rates of rejection: Aetna US Healthcare (29%), Freedom Health FL (29%), Humana Health Plan (29%)

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“This is a very troubling and frankly dangerous finding,” said Alliance for Patient Access Executive Director Brian Kennedy. “The patients prescribed this medicine have extremely high LDL cholesterol, and statins alone are not sufficient to reduce their risk of heart attack. With these new cholesterol-lowering drugs, patients’ risk of heart attack decreases, yet insurance companies are too often refusing to cover the medicine.”

PCSK9 inhibitors work by extending the lifespan of a receptor on the liver that clears “bad” cholesterol.  Clinical trials data show that PCSK9 inhibitors can lower LDL cholesterol more than statins alone and can also reduce the associated risks of heart attack and stroke.

The Institute for Patient Access report card highlights the 15 Florida health plans that process the most PCSK9 inhibitor claims, ranking them based on the number of rejections issued. The least patient-friendly plans were the Federal Employee Benefit Plan, with a rejection rate of 77%, and Express Scripts at 76%. Also denying claims at a far higher rate than the state average were Cigna Healthcare, 63%, and Florida Blue, 61%. Humana Health Plan, Aetna and Freedom Health Florida denied fewer than 30% of claims.

This is the first in a series of state report cards that the Institute for Patient Access will release in 2017 to highlight barriers to access.

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The Alliance for Patient Access is a national network of physicians dedicated to ensuring patient access to approved therapies and appropriate clinical care.
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