Alabama Health Plans deny treatment for high cholesterol

The Institute for Patient Access released a new Health Plan Coverage Report Card claiming that Alabama insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors 53 percent of the time. The report card reveals that health plans reject more than one out of every two 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 Alabama managed care organizations, including commercial plans, Medicare and managed Medicaid.

Read more at the Alabama Political Reporter

***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%)

View the full Report Card

“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.

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BACKGROUND

Institute for Patient Access

PCSK9 Inhibitors Texas Report Card

Alliance for Patient Access

New Collaboration Improves Access to Treatment for Familial Hypercholesteremia (FH) Patients Most at Risk for Early Heart Attacks and Death

PASADENA, Calif., March 15, 2017 /PRNewswire-USNewswire/ -- The FH Foundation, a patient-centered non-profit dedicated to research, advocacy, and education of all forms of familial hypercholesterolemia (FH), today announced its collaboration with Express Scripts, a leading pharmacy benefit manager, to improve pharmacy coverage for patients with FH, an inherited genetic disorder that causes high LDL-cholesterol from birth. With a more comprehensive set of diagnostic criteria, a broader group of patients will have access to cutting-edge PCSK9 inhibitor treatment, as appropriate.

Read more at PRNewswire. 

***PRESS RELEASE*** Florida 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 today released a new Health Plan Coverage Report Card highlighting the rates at which Florida 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 August 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims for Florida managed care organizations, including commercial plans, Medicare and managed Medicaid.

Key Florida Findings:

• 45% average rejection rate
• 3,784 total rejections
• 1,197 appeals
• Highest rates of rejection: Federal Employee Benefit Plan (77%), Express Scripts (76%), Cigna Healthcare (63%)
• Lowest rates of rejection: Aetna US Healthcare (29%), Freedom Health FL (29%), Humana Health Plan (29%)

“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 15 Florida 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 77%, and Express Scripts at 76%. Also denying claims at a far higher rate than the state average were Cigna Healthcare, 63%, and Florida Blue, 61%. Humana Health Plan, Aetna and Freedom Health Florida denied fewer than 30% of claims.

This is the first in a series of state report cards that the Institute for Patient Access will release in 2017 to highlight barriers to access.