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 Georgia insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject 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 Georgia managed care organizations, including commercial plans, Medicare and managed Medicaid.
Key Georgia Findings:
- 50% average rejection rate
- 1,515 total rejections
- 333 appeals
- Highest rates of rejection: Federal Employee Benefit Plan (84%), Express Scripts (73%), Anthem (73%), Georgia State Health Benefit Plan (71%)
- Lowest rates of rejection: CVS Health (55%), United Health Group (54%), Humana Health Plan (34%), Aetna US Healthcare (27%)
“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 10 Georgia 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 Express Scripts at 73%. Also denying claims at a far higher rate than the state average were Anthem, 73%, and Georgia State Health Benefit Plan, 71%. Aetna US Healthcare had the lowest rejection rate but still denied nearly one-third 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.