New York Health Plans Reject More than 1/3 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 New York insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject 40 percent of 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 New York managed care organizations, including commercial plans, Medicare and managed Medicaid.
Key New York Findings:
· 40% average rejection rate
· 1,358 total rejections
· 615 appeals
· Highest rates of rejection: New York State Government Employees (81%), Express Scripts (71%), HealthNow BCBS (58%), Fidelis Care NY (53%)
· Lowest rates of rejection: Independent Health (23%), Humana Health Plan (21%), Aetna US Healthcare (17%), Epic New York (10%)
“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 16 New York 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 New York State Government Employees, with a rejection rate of 81%, and Express Scripts at 71%. Also denying claims at a far higher rate than the state average were HealthNow BCBS, 58%, and Fidelis Care NY, 53%. Epic New York had the lowest rejection rate at 10%.
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.