Alliance for Patient Access / What's New / ***PRESS RELEASE*** California Health Plans Reject More than One-Third of Claims for High Cholesterol Treatment

***PRESS RELEASE*** California Health Plans Reject More than One-Third of Claims for High Cholesterol Treatment

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 California insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject more than one out of every three claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from July 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims for California managed care organizations, including commercial plans, Medicare and managed Medicaid.

Key California Findings:

  • 39% average rejection rate
  • 2,892 total rejections
  • 1,585 appeals
  •  Highest rates of rejection: Federal Employee Benefit Plan (84%), Blue Shield of CA (66%), Express Scripts (64%), Scan Health Plan (52%)
  • Lowest rates of rejection: Humana Health Plan (26%), Wellcare Management Group (19%), Rite Aid (13%), MPC Managed Pharmacy Care (1%)


“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 18 California health plans that process the most PCSK9 inhibitor claims, ranking them based on the number of rejections issued. The least patient-friendly plans were the Federal Employee Benefit Plan, with a rejection rate of 84%, and Blue Shield of CA at 66%. Also denying claims at a far higher rate than the state average were Express Scripts, 64%, and Scan Health Plan, 52%. Humana Health Plan, Wellcare Management Group and Rite Aid had the lowest rejection rates, denying fewer than 30% 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.





Institute for Patient Access

PCSK9 Inhibitors California Report Card

Alliance for Patient Access

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The Alliance for Patient Access is a national network of physicians dedicated to ensuring patient access to approved therapies and appropriate clinical care.
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