Access to Life-Saving Medications is Being Denied

Rejected Insurance Claim Form

 

“The fight for my PCSK9 took almost two years and highlights the need for us to continue in the fight for access to life-saving medications for all heart patients.” – Donnette Smith, President of Mended Hearts.

The non-profit Institute for Patient Access is in the process of revealing health care report cards for all states. These reports show insurers deny coverage at an extremely high rate for cholesterol-lowering drugs known as PCSK9 inhibitors. The data, captured from January to December 2017, reflects PCSK9 inhibitor claims for state managed care organizations, including commercial plans, Medicare, Medicaid and managed Medicaid.

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

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.

State Report Card Highlights

Within the six states that the report cards have been released, the data shows the denial rate

Key Alabama Findings:

  • 35% average rejection rate
  • 1,743 rejections
  • 21% appeals rate
  • Highest rates of rejection: BCBS Alabama (48%), CVS Health (45%), Express Scripts (37%), Cigna Healthcare (33%)
  • Lowest rates of rejection: Humana Health Plan (19%), State Employees Health Insurance SEHIP (8%)

Key California Findings:

  • 24% average rejection rate
  • 6,372 rejections
  • 35% appeals rate
  • Highest rates of rejection: Blue Shield of CA (60%), Express Scripts (48%), Centene (46%), Anthem (40%)
  • Lowest rates of rejection: Aetna (14%), Humana Health Plan (9%)

Key Georgia Findings:

  • 31% average rejection rate
  • 3,180 rejections
  • 25% appeals rate
  • Highest rates of rejection: Anthem (80%), Georgia State Health Benefit Plan (54%), Tricare Military Health SVC SYS (53%), Express Scripts (49%)
  • Lowest rates of rejection: Cigna Healthcare (18%), Humana Health Plan (13%)

Key Mississippi Findings:

  • 31% average rejection rate
  • 742 rejections
  • 19% appeals rate
  • Highest rates of rejection: BCBS Mississippi (97%), State of Mississippi Employees (94%), Express Scripts (79%), United Health Group (45%)
  • Lowest rates of rejection: Humana Health Plan (14%), WellDyneRx (0%)

Key New York Findings:

  • 27% average rejection rate
  • 4,249 total rejections
  • 34% appeals rate
  • Highest rates of rejection: Fidelis Care NY (43%), Express Scripts and United Health Group (34%), Independent Health (25%)
  • Lowest rates of rejection: Aetna (12%), Humana Health Plan (9%)

Key Texas Findings:

  • 30% average rejection rate
  • 7,396 rejections
  • 27% appeals rate
  • Highest rates of rejection: Federal Employee Benefit Plan (82%), Tricare Military Health SVC SYS (44%), United Health Group (41%), Express Scripts (39%)
  • Lowest rates of rejection: Aetna (18%), Humana Health Plan (12%)

While the state data is still being gathered, Mended Hearts wanted to share this important information as it is received. If you live in a state where the report card has not been published yet, please stay tuned for more information as it is received.

Mended Hearts priority is to continue to push for access to these important and live-saving treatments for heart patients. If you have been denied access to treatment, we want to hear from you.

If you would like to get involved, share your story, or if you have questions, please contact Andrea Baer, Director of Patient Advocacy at andrea.baer@mendedhearts.org


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