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 Mississippi insurers deny coverage for one-third of patient claims for cholesterol-lowering drugs known as PCSK9 inhibitors. Two health plans rejected over 90 percent of claims. The data, captured from January to December 2017, reflects PCSK9 inhibitor claims for Mississippi managed care organizations, including commercial plans, Medicare, Medicaid and managed Medicaid.
Key Mississippi Findings:
- 31% average rejection rate
- 742 rejections
- 19% appeals rate
- Highest rates of rejection: BCBS Mississippi (97%), State of Mississippi Employees (94%), Express Scripts (79%), United Health Group (45%)
- Lowest rates of rejection: Humana Health Plan (14%), WellDyneRx (0%)
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 got their LDL levels down to as low as 19. Data also show that PCSK9 inhibitors can reduce the risk of heart, stroke and death.
The therapies are approved for:
- Patients with a genetic predisposition toward high LDL cholesterol, known as familial hypercholesterolemia
- 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 10 Mississippi health plans that process the most PCSK9 inhibitor claims, ranking them based on the percentage of rejections issued. The least patient-friendly plans were BCBS Mississippi at a staggering 97 percent, State of Mississippi Employees at 94 percent, Express Scripts at 79 percent, and United Health Group at 45 percent. Humana Health Plan and WellDyneRx had the lowest rejection rates at 14 and zero percent respectively.
This report card is one in a series released by the Institute for Patient Access to highlight barriers to patient access.
To view last year’s Mississippi report click here.