Health Plan Report Cards Reveal High Rejection Rate for Cholesterol Meds

Rejection is never pleasant.  But for the 34,459 patients whose health plans refuse to cover advanced treatment for high cholesterol, it could also be deadly.

Feedback from patients and physicians has painted a clear picture since cholesterol-lowering PCSK9 inhibitors became available in 2015: patients who need these drugs to stave off heart attacks and stroke can’t always access them.  A new series of health plan report cards from the Institute for Patient Access now offers the statistics to confirm that story.

Report Card Findings

Report cards issued by IfPA capture claims information collected by a national data supplier between July 20, 2015 and July 21, 2016.  In its national report card, which reflects claims data from all 50 U.S. states, IfPA cites:

  • 34,459 PCSK9 inhibitor rejections nationwide
  • 43% rejection rate
  • 12,108 appeals.

It also sheds light on which health plans reject the most patients and at the highest rates:
Highest Rejection Rates:

  • Federal Employee Benefit Plan: 85%
  • Express Scripts: 62%
  • Anthem: 62%
  • Cigna Healthcare 51%.

Highest Rejection Volume:

  • United Health Group: 5,453 rejections
  • Humana Health Plan: 4,542 rejections
  • CVS Health: 2,990 rejections
  • Express Scripts: 2,515 rejections.

The national plans ranked are those that processed at least 1,000 claims for PCSK9 inhibitors during the timeframe identified.

IfPA has also issued individual report cards for 10 states.  Of states with at least nine health plans covering no fewer than 50 PCSK9 inhibitor claims each, the following exhibited the highest rejection rates:

The report card data has been featured in a series of infographics from the Partnership to Advance Cardiovascular Care.  Partnership Executive Director Ryan Gough explained, “This data is not entirely surprising, but nevertheless devastating to patients.  Though we see more and more clinical data about these medications’ ability to reduce stroke and heart attack risk, we still see too many patients who cannot obtain the PCSK9 inhibitors their doctors prescribe.”  The group is contacting state insurance commissioners and health plans directors with the highest rejection rates to discuss how to address the problem.

Alliance for Patient Access Executive Director Brian Kennedy expressed similar sentiments, calling the findings, “very troubling and frankly dangerous.” “Now it’s up to policymakers to act upon this data so that at-risk patients who don’t adequately respond to statins can access therapies that will work for them,” Kennedy explained.

About PCSK9 Inhibitors

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 got their LDL levels down to as low as 19 and can reduce the risk of heart, stroke and cardiovascular death by 20 percent.

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.
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