California Insurer Rethinks Restrictions on Cholesterol Medication

July 1, 2021

Californians in danger of a heart attack or stroke now have help reducing a key risk factor. 

One of the state’s largest commercial insurers, Blue Shield of California, has eased access to PCSK9 inhibitors. Called a “game changer in cholesterol management,” the medication can significantly reduce LDL cholesterol for patients who don’t respond well to statins.

Blue Shield of California Reversed Course

The health plan’s approach is an about-face from the extreme position it announced in January, when it removed all PCSK9s from its standard formulary. For the last six months, patients were required to secure a medical necessity waiver from their physician before the plan would cover the medication. 

Such an approach could worsen health inequities statewide, pointed out Lindsay Videnieks, manager of the Alliance for Patient Access’ Cardiovascular Disease Working Group. “Even before the pandemic, communities of color experienced reduced access to [PCSK9 inhibitors],” wrote Videnieks in a letter to Blue Shield of California.

The letter also cited PSCK9 inhibitors’ clinical advantages and the added administrative burden of Blue Shield of California’s policy on health care providers. It was cosigned by the Association of Black Cardiologists, the American Society for Preventive Cardiology and the Preventive Cardiovascular Nurses Association, along with other organizations and a long list of individual clinicians.

Access Challenges Abound

California is far from the only state where cardiovascular disease patients have trouble accessing the treatments their physicians prescribe. 

An analysis of national claims data found that commercial plans denied more than a quarter of all PCSK9 claims, despite high-risk patients’ meeting criteria for the medication. And in Mississippi, the largest private insurer in the state denied 97% of claims for PCSK9 inhibitors as recently as 2018. 

Advocates for patient-centered care are hopeful that Blue Shield of California’s new policy is the beginning of a trend that will see other insurers following their lead. Cardiovascular conditions alarmingly account for one in every four deaths. Turning that tide will largely depend on patients accessing the full range of available treatments.  

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