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 Texas insurers deny coverage for nearly one-third of patient claims for cholesterol-lowering drugs known as PCSK9 inhibitors. The data, captured from January to December 2017, reflects PCSK9 inhibitor claims for Texas managed care organizations, including commercial plans, Medicare, Medicaid and managed Medicaid.
Key Texas Findings:
- 30% average rejection rate
- 7,396 rejections
- 27% appeals rate
- Highest rates of rejection: Federal Employee Benefit Plan (82%), Tricare Military Health SVC SYS (44%), United Health Group (41%), Express Scripts (39%)
- Lowest rates of rejection: Aetna (18%), Humana Health Plan (12%)
The Federal Employee Benefit Plan is a program through which insurance companies provide health benefits to civil servants and employees of the U.S. Government. Plan details can vary state to state.
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 to get 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 11 Texas health plans that process the most PCSK9 inhibitor claims, ranking them based on the percentage of rejections issued. The least patient-friendly plans were Federal Employee Benefit Plan at 82 percent, Tricare Military Health SVC SYS at 44 percent, United Health Group at 41 percent, and Express Scripts at 39 percent. Aetna and Humana Health Plan had the lowest rejection rates at 18 and 12 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 Texas report click here.