WASHINGTON – On Friday, June 23, the Partnership to Advance Cardiovascular Health (PACH) will launch a petition on Change.org directed at the National Association of Insurance Commissioners in response to the alarming rejection rates that qualifying patients across the country face in accessing new, groundbreaking, cholesterol-lowering medications known as PCSK9 inhibitors. The petition will be promoted at a series of health forums on the status of cardiovascular health in states where there is an enhanced need for access to cholesterol-lowering therapies but health plan barriers remain high. Many health plans around the country are using restrictive plan designs and utilization management tools to force patients onto less effective therapies in spite of physicians’ recommendations and compelling data.
The petition’s initial launch will occur on Friday at the first cardiovascular health forum in Birmingham, Alabama, which will focus on high rates of cardiovascular disease in Alabama and barriers that patients face in accessing cholesterol-lowering drugs. Data from the Institute for Patient Access (IfPA) shows Alabama health plans reject more than 50 percent of claims for PCSK9 inhibitors. The least patient-friendly Alabama plans were the Federal Employee Benefit Plan, with a rejection rate of 87 percent, and Blue Cross Blue Shield Alabama at 60 percent.
A National Health Plan Coverage Report Card from IfPA highlights the rates at which insurers nationwide deny patients coverage for PCSK9 inhibitors. The report card reveals that health plans reject 43 percent of claims submitted for coverage. The data, collected from July 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims from all 50 states for managed care organizations, including commercial plans, Medicare and managed Medicaid.
Research shows that PCSK9 inhibitors can reduce the risk of heart, stroke and cardiovascular death by 20 percent, yet many qualifying patients do not have access to the therapies prescribed by their physician.
National Health Plan Coverage Report Card Key Findings:
- 43% average rejection rate
- 80,775 claims
- 34,459 total rejections
- 12,108 appeals
- Highest rates of rejection: Federal Employee Benefit Plan (85%), Express Scripts (62%), Anthem (62%), Cigna Healthcare (51%)
- Lowest rates of rejection: Health Care Services Corporation HCSC (39%), Humana Health Plan (27%), Rite Aid (27%), Aetna US Healthcare (26%)
- Highest volume of rejection: United Health Group (5,453 rejections), Humana Health Plan (4,542 rejections), CVS Health (2,990 rejections), Express Scripts (2,515 rejections)
Some states had even higher rejections rates than the national average.
- Alabama, 53%
- Mississippi, 53%
- Georgia, 50%
- South Carolina, 48%
- Kentucky, 48%
- Michigan, 47%
- Texas, 46%
- Florida, 45%
- Ohio, 45%
PCSK9 inhibitors work by extending the lifespan of a receptor on the liver that clears LDL, or “bad” cholesterol. Patients, some with a genetic condition called familial hypercholesterolemia, or FH, are at increased risk for cardiac events such as heart attack and stroke because of extremely high levels of LDL. 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.