New health plan report card analyzes PCSK9 inhibitor claims for managed care organizations
WASHINGTON – The Institute for Patient Access released a new Health Plan Coverage Report Card highlighting the rates at which Ohio insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject nearly 50 percent of 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 Ohio managed care organizations, including commercial plans, Medicare and managed Medicaid.
Key Ohio Findings:
- 45% average rejection rate
- 1,483 total rejections
- 605 appeals
- Highest rates of rejection: CareSource Management Group (91%), Express Scripts (61%), Anthem (60%), Cigna (57%)
- Lowest rates of rejection: State Teachers Retirement System of Ohio (34%), Medical Mutual (33%), Aetna (22%), Humana (22%)
“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 13 Ohio health plans that process the most PCSK9 inhibitor claims, ranking them based on the number of rejections issued. The least patient-friendly plans were CareSource Management Group, with a rejection rate of 91%, and Express Scripts at 61%. Also denying claims at a far higher rate than the state average were Anthem, 60%, and Cigna, 57%. Aetna and Humana had the lowest rejection rates, denying 22% of claims.
This report card is one in a series to be released by the Institute for Patient Access in 2017 to highlight barriers to patient access.