South Carolina Health Plans Reject Over Half of 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 South Carolina insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject nearly 50 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 South Carolina managed care organizations, including commercial plans, Medicare and managed Medicaid.
Key South Carolina Findings:
- 48% average rejection rate
- 602 total rejections
- 123 appeals
- Highest rates of rejection: BCBS SC (82%), Cigna Healthcare (65%), CVS Health (56%), Express Scripts (54%)
- Lowest rates of rejection: United Health Group (49%), SC State Employees (37%), Humana Health Plan (34%), Aetna US Healthcare (30%)
“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 nine Alabama 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 Federal Employee Benefit Plan, with a rejection rate of 87%, and BCBS AL at 60%. Also denying claims at a higher rate than the state average were Express Scripts, 59%, and Cigna Healthcare, 59%. Humana Health Plan had the lowest rejection rate, though they still denied almost a third of claims.
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.