New health plan report card analyzes PCSK9 inhibitor claims for managed care organizations; BCBS Mississippi rejected 100 percent of claims
WASHINGTON – The Institute for Patient Access released a new Health Plan Coverage Report Card highlighting the rates at which Mississippi insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject more than 50 percent of claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from August 2015 to July 21, 2016 by a national data supplier, reflects PCSK9 inhibitor claims for Mississippi managed care organizations, including commercial plans, Medicare and managed Medicaid.
Key Mississippi Findings:
- 53% average rejection rate
- 501 total rejections
- 107 appeals
- Highest rates of rejection: BCBS Mississippi (100%), Tricare Military Health SVC SYS (70%), Express Scripts (67%), United Health Group (56%)
- Lowest rates of rejection: CVS Health (49%), Aetna U.S. Healthcare (37%), Humana Health Plan (35%)
“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 eight Mississippi health plans that process the most PCSK9 inhibitor claims, ranking them based on the percentage of rejections issued. The least patient-friendly plans was BCBS Mississippi, which rejected 100 percent of claims. Also denying claims at a far higher rate than the state average were Tricare Military Health SVC SYS, 70%, Express Scripts, 67%, and United Health Group, 56%. Aetna U.S. Healthcare and Humana Health Plan had the lowest rejection rates, at 37% and 35% respectively.
This report card is one in a series released by the Institute for Patient Access in 2017 to highlight barriers to patient access.