Insurance plans denied coverage for almost 80K claims for cholesterol-lowering drugs

A report issued by the Institute for Patient Access suggests commercial healthcare insurance plans, as well as Medicare, Medicaid and Medicaid managed care, denied coverage for almost 80,000 insurance claims for PCSK9 inhibitors in 2017.

“This report is deeply troubling for patients and their providers,” said Brian Kennedy, executive director of Alliance for Patient Access. “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.”

While results of the ODESSEY and FOURIER trials have shown promise in PCSK9 inhibitors lowering bad cholesterol, there is skepticism among cardiologists.

There was a total of 292,143 claims and 78,664 of those claims were denied coverage in 2017. The report noted a 46 percent initial rejection rate and a 26 percent average final rejection rate, among claims.

The highest rates for rejection from commercial managed care organizations include:

  • Federal Employee Benefit Plan—83 percent
  • Anthem—76 percent
  • CVS Health—66 percent
  • United Health Group—62 percent 

The highest rates for rejection from Medicare managed care organizations include:

  • United Health Group—21 percent
  • Anthem—21 percent
  • Wellcare Management Group—20 percent
  • CVS Health—17 percent

“Rejection rates are far too high, and patients who could benefit from these medications still run into access barriers,” said Ryan Gough, executive director of Partnership to Advance Cardiovascular Health. “We know that one American has a heart attack every 40 seconds. Fifteen percent of people who suffer a heart attack die from it. And heart attack is one of the most expensive hospital discharge diagnoses. Health plans may think they’re reducing costs but leaving these patients vulnerable to stroke and heart attack ends up costing everybody.”