Alliance for Patient Access / What's New / ***PRESS RELEASE*** Texas Health Plans Reject Nearly Half of Claims for High Cholesterol Treatment

***PRESS RELEASE*** Texas Health Plans Reject Nearly Half 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 Texas insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject nearly one out of every two 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 Texas managed care organizations, including commercial plans, Medicare and managed Medicaid.

Key Texas Findings:

  • 46% average rejection rate
  • 2,877 total rejections
  • 745 appeals
  • Highest rates of rejection: Federal Employee Benefit Plan (91%), Express Scripts (73%), Teacher Retirement System of Texas TRS (64%)
  • Lowest rates of rejection: Humana Health Plan (31%), Tricare Military Health SVC SYS (31%), Aetna US Healthcare (28%)



“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 Texas 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 91%, and Express Scripts at 73%. Also denying claims at a far higher rate than the state average were Teacher Retirement System of Texas TRS, 64%, and Wellcare Management Group, 61%. Humana Health Plan, Tricare Military Health SVC SYS and Aetna had the lowest rejection rates, though they still denied roughly 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 Texas 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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