National health plan report card analyzes 2017 PCSK9 inhibitor claims for managed care organizations
WASHINGTON – The non-profit Institute for Patient Access released a new Health Plan Coverage Report Card revealing that nationwide, insurers denied coverage for nearly 80,000 patient claims for cholesterol-lowering drugs known as PCSK9 inhibitors. The data, captured from January to December 2017, reflects PCSK9 inhibitor claims for Medicare, Medicaid, Medicaid managed care, and commercial managed care organizations.
Key National Findings:
- 46% average initial rejection rate
- 26% average final rejection rate
- 78,664 rejections
- 292,143 total claims
- Highest rates of rejection for commercial managed care organizations: Federal Employee Benefit Plan (83%), Anthem (76%), CVS Health (66%), United Health Group (62%)
- Highest rates of rejection for Medicare managed care organizations: United Health Group (21%), Anthem (21%), Wellcare Management Group (20%), CVS Health (17%)
PCSK9 inhibitors block the PCSK9 protein from destroying a receptor on the liver that clears bad cholesterol. By prolonging the life of the receptor, the drugs increase the amount of LDL cholesterol that’s cleared from the body. Research shows that the drug allows some patients to get their LDL levels down an average of 59 percent. Data also show that PCSK9 inhibitors can reduce the risk of heart, stroke and death.
The therapies are approved for:
- Patients with the genetic disorder familial hypercholesterolemia (FH), who are born with severely elevated LDL (“bad”) cholesterol levels, putting them at increased risk for early, aggressive cardiovascular disease
- Those with atherosclerotic heart or blood vessel problems who don’t adequately respond to traditional treatments.
STATEMENT FROM ALLIANCE FOR PATIENT ACCESS EXECUTIVE DIRECTOR BRIAN KENNEDY:
“This report is deeply troubling for patients and their providers. Health plans are blocking heart patients from accessing the medication that their physicians prescribe. These are patients who are at risk for adverse cardiac events like heart attack and stroke and who don’t respond adequately to traditional cholesterol-lowering statins. This report shows that health plans are cutting costs at patients’ expense.”
STATEMENT FROM PARTNERSHIP TO ADVANCE CARDIOVASCULAR HEALTH EXECUTIVE DIRECTOR RYAN GOUGH:
“Rejection rates are far too high, and patients who could benefit from these medications still run into access barriers. We know that one American has a heart attack every 40 seconds. Fifteen percent of people who suffer a heart attack die from it. And heart attack is one of the most expensive hospital discharge diagnoses. Health plans may think they’re reducing costs, but leaving these patients vulnerable to stroke and heart attack ends up costing everybody.”
The Institute for Patient Access report card highlights the health plans that process the most PCSK9 inhibitor claims, ranking them based on the percentage of rejections issued. The least patient-friendly commercial plans were the Federal Employee Benefit Plan at 83 percent, Anthem at 76 percent, CVS Health at 66 percent, and United Health Group at 62 percent.
This report card is one in a series released by the Institute for Patient Access to highlight barriers to patient access.