The Alliance for Patient Access / What's New / ***PRESS RELEASE*** Health Plans Nationwide Reject 43 percent of Claims for High Cholesterol Treatment

***PRESS RELEASE*** Health Plans Nationwide Reject 43 percent of Claims for High Cholesterol Treatment

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

 WASHINGTON – The Institute for Patient Access released a new National Health Plan Coverage Report Card highlighting the rates at which insurers nationwide deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject 43 percent of claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from July2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims from all 50 states for managed care organizations, including commercial plans, Medicare and managed Medicaid.

Research shows that PCSK9 inhibitors can reduce the risk of heart, stroke and cardiovascular death by 20 percent

Key Findings:

  • 43% average rejection rate
  • 80,775 claims
  • 34,459 total rejections
  • 12,108 appeals
  • Highest rates of rejection: Federal Employee Benefit Plan (85%), Express Scripts (62%), Anthem (62%), Cigna Healthcare (51%)
  • Lowest rates of rejection: Health Care Services Corporation HCSC (39%), Humana Health Plan (27%), Rite Aid (27%), Aetna US Healthcare (26%)
  • Highest volume of rejection: United Health Group (5,453 rejections), Humana Health Plan (4,542 rejections), CVS Health (2,990 rejections), Express Scripts (2,515 rejections)

“These findings are troubling and frankly dangerous,” 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 11 health plans that process the most PCSK9 inhibitor claims, ranking them based on the number of rejections issued. The least patient-friendly plans were Federal Employee Benefit Plan, with a rejection rate of 85%, and Express Scripts and Anthem at 62%. Also denying claims at a far higher rate than the state average was Cigna Healthcare, 51%. Aetna had the lowest rejection rate, but still denied nearly one third of claims.

This national report card was preceded by a series of state report cards released by the Institute for Patient Access earlier this year highlight barriers to patient access.
 
Alabama Health Plan Coverage Report Card
California Health Plan Coverage Report Card
Florida Health Plan Coverage Report Card
Georgia Health Plan Coverage Report Card
Kentucky Health Plan Coverage Report Card
Michigan Health Plan Coverage Report Card
New York Health Plan Coverage Report Card
Ohio Health Plan Coverage Report Card
South Carolina Health Plan Coverage Report Card
Texas Health Plan Coverage Report Card

 
BACKGROUND
Institute for Patient Access
PCSK9 Inhibitors National Report Card
Alliance for Patient 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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