The top priority of any physician or provider in the medical field should be acquiring the most appropriate therapy for patients.
This is especially true for patients with heart disease, the leading cause of death nationally and in our own state, accounting for 20,000 Georgians’ deaths each year.
Sadly, this is not always the priority of the payers in American health care.
As a family doctor with almost 25 years in practice, I’ve seen the difficulties my patients with heart disease experience in filling the prescriptions that could prevent heart and vascular disease and save their lives.
I know this as someone with heart disease myself, who recently passed both the ages that my grandfather died of a heart attack and that my father, who thankfully survived, had a heart attack.
I have stayed healthy longer than my father and grandfather thanks in part to a medication that does wonders to keep my LDL cholesterol low.
A medication, I might add, that my insurance company denied covering.
I take a PCSK9 inhibitor, which is a newer cholesterol drug class that can be helpful to as many as 10 million Americans suffering from heart disease and high cholesterol for whom older statin drugs are not enough. These newer drugs have been shown to reduce cholesterol by more than 60%.
For someone like me, whose interest in heart disease treatment stems from my family history, this number is astounding.
Yet most patients who are prescribed a PCSK9 by their doctors are denied coverage by the pharmacy benefit managers, who manage their prescription drug benefits.
One study found that patients who were prescribed a PCSK9 were rejected by their PBM 80% of the time on the first attempt, just as I was. Despite clearly meeting the criteria for qualification as approved by the FDA, more than half were ultimately rejected despite appeals.
Even Medicare patients are having trouble. The initial list price of PCSK9s landed them on Part D’s “specialty” tier, which requires out-of-pocket costs for beneficiaries up to a third of the drug’s price. This has proved to be too expensive for many patients.
In response, PCSK9 manufacturers took the unprecedented step of reducing the price for the drugs by 60%. Unfortunately, nearly 40% of patients on commercial insurance still had their PCSK9 prescriptions rejected.
Many Part D beneficiaries have seen these drugs simply moved to their “non-preferred” brand tier, which can require even higher cost-sharing than the specialty tier — up to 50%.
Here in Georgia, up to 70% of Medicare patients face steep monthly costs in 2020, even after the drug price was reduced by over half.
So what can be done about it?
Georgia U.S. Reps. Buddy Carter and Doug Collins have both been champions for improving affordable access to prescription drugs. They are leading the fight to bring more federal oversight to PBMs, but they need your help.
Let your own state and federal representatives know that insurance companies should stop standing between patients with serious illnesses and lifesaving medications.
In our country, where we know our Medicare system is stressed, our lawmakers need to be wise with our resources. Preventing heart attacks with PCSK9s will save tremendous amounts of money and lives.
Reducing disability and long-term care cost is the least we can do for our seniors and our taxpayers.
Dr. Andrew Reisman practices family medicine at the Longstreet Clinic in Oakwood. He is president of the Medical Association of Georgia and a member of the Georgia Composite Medical Board, the American Medical Association, the Georgia Academy of Family Practitioners and the Hall County Medical Society.