Health plan report card analyzes 2017 PCSK9
inhibitor claims for managed care organizations

The non-profit Institute for Patient Access released a new Health Plan Coverage Report Card revealing that Florida insurers denied coverage for over 8,500 patient claims for cholesterol-lowering drugs known as PCSK9 inhibitors. Thedata, captured from January to December 2017, reflects PCSK9 inhibitor claims for Florida managed care organizations, including commercial plans, Medicare, Medicaid and managed Medicaid.

Key Florida Findings:

• 29% average rejection rate
• 8,584 rejections
• 27% appeals rate
• Highest rates of rejection: Federal Employee Benefit Plan (84%), Florida Blue (51%), Tricare Military Health SVC SYS (51%), Express Scripts (47%)
• Lowest rates of rejection: Aetna (18%), Humana Health Plan (12%)

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 an average of 59 percent. Data also show that PCSK9 inhibitors can reduce the risk of heart, stroke and death.

The therapies are approved for:

• Patients with the genetic disorder familial hypercholesterolemia (FH), who are born with severely elevated LDL (“bad”) cholesterol levels, putting them at increased risk for early, aggressive cardiovascular disease
• 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 SETH BAUM, MD, PREVENTIVE CARDIOLOGIST IN BOCA RATON, FLORIDA: 

“I know first-hand about the barriers my patients face in accessing these life-saving medications. As a physician I am frustrated when I prescribe medications to patients who need them – only to have their health plan flatly reject them. These patients are at high risk for heart attack and stroke and these medications can help reduce their chances of a cardiac event; yet health plans continue to get in the way. We must find a way to make sure patients have access to these novel and FDA-approved medications.”

The Institute for Patient Access report card highlights the 10 Florida health plans that process the most PCSK9 inhibitor claims, ranking them based on the percentage of rejections issued. The least patient-friendly plans were the Federal Employee Benefit Plan at 84 percent, Florida Blue at 51 percent, Tricare Military Health SVC SYS at 51 percent, and Express Scripts at 47 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 Florida report click here.