Suffered a heart attack? Diagnosed with cardiovascular disease? Confirmed you have genetic high cholesterol?  

None of that may matter to your health plan.  

As new data reveals, insurers are still saying “no” to patients whose physicians prescribe a cholesterol-lowering PCSK9 inhibitor.  Even one in three at-risk patients who meet traditional criteria for coverage.

The finding is part of a 2019 national access report card from the Institute for Patient Access, which reflects 2018 insurance claims data from across the country.  

Key Findings

The data suggests an alarming one-size-fits-all approach to coverage denials, with commercial rejection rates hovering around 35 percent for patients who exhibit risk factors that may expose them to heart attack or stroke:    

Commercial rejection rates for the general population were 57% initially, with 38% patients not receiving their medication. That means that physicians were sometimes able to appeal a health plan’s rejections – but not nearly often enough.  All in all, Medicare, Medicaid, Medicaid managed care and commercial health plans blocked more than 88,000 patients from getting their doctor-prescribed PCSK9 inhibitor.

Of nationwide plans with at least 3,000 claims for PCSK9 inhibitors, the following rejected patients’ claims at the highest rate:

Several of these plans also had among the highest rejection rates reported in the 2018 IfPA report card.

Notably, 26 percent of plans denied every single claim for PCSK9 inhibitors.

Reactions

The rejection of high-risk patients is unsettling for patient advocates.  Just ask cardiologist and Partnership to Advance Cardiovascular Health Board President Dharmesh Patel, MD.  

“Anytime a health plan refuses a medicine that a patient’s physician has prescribed and deemed appropriate, it’s worrisome,” Patel explained.  “Yet here we see the health plan not only getting between the patient and physician, but also denying patients who have a proven, documented risk of heart attack or stroke.  Some have genetic cholesterol, meaning they may already have lost a family member to heart attack or stroke,” Patel noted, adding “The liberties that health plans are taking with patients’ lives is indefensible.”

Cardiologist Seth Baum, MD, echoed these concerns.  “It’s obvious,” Baum noted, “that prior authorization is a barrier preventing patients from receiving appropriate care that has been prescribed by their doctors.  Here we have innovative medicines that can reduce the risk of stroke, heart attack and death; yet, many patients are simply not being allowed to use them.”

Baum is chair of the Alliance for Patient Access’ Cardiovascular Disease Working Group.

About PCSK9 Inhibitors

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 and can reduce the risk of heart, stroke and cardiovascular death by 20 percent.

The therapies are approved for:

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