Dr. Seth J. Baum on the Patient's Role in Getting PCSK9 Inhibitors Approved by Payers

MARCH 25, 2017

It remains unclear why insurers approve some patients for PCSK9 inhibitors while denying others with similar clinical characteristics, according to Seth J, Baum, MD, FACC, FACPM, FAHA, FNLA, FASPC, president of the American Society for Preventive Cardiology, who presented an abstract on the subject at the American College of Cardiology 66th Scientific Session. However, Baum said there are steps clinicians, and more importantly patients, can take to improve the chances of payer approval.  

What characteristics make patients more likely to be approved by payers for PCSK9 inhibitors?

It would be great to really know what characteristics make patients more likely to be approved or denied for PCSK9 inhibitors. We had an abstract at this meeting showing that we can’t really tell, so we looked at approval and denial rates for patients on high-intensity statins, on high-intensity statins and ezetimibe, on dual antiplatelet therapy, which is really synonymous for ASCVD [atherosclerotic cardiovascular disease], and there was no significant difference between approval and denial for those categories.

So at this point, it’s looking pretty haphazard, almost capricious, how approval and denials are actually being processed through the payers.  

Is there anything patients and clinicians can do to make PCSK9 inhibitor approval more likely?

Patients and clinicians can make things easier or better. I would say the most important thing to do is for patients to become involved. Patients absolutely have the loudest voice.

When a patient contacts an insurance company and says, “Hey, I was prescribed this medication and denied this medication, yet it’s on your formulary and my doctor believes that I need it,” the clock actually starts at that point and the patient’s grievance is recorded. When a doctor calls, it doesn’t happen, so we have to do that in parallel: the patient has to be involved, the doctor has to be involved.

From the doctor’s standpoint, the important thing to do is to document, document, document, just make sure you fill out the prior authorization perfectly. I’d like to suggest that in addition to the prior authorization required by the company, use the simplified prior authorization that we’re going to have online through Clinical Cardiology, and when enough people do that I think we’re going to show the insurance companies that they need to utilize this simplified prior authorization.