2 weeks ago
Heart Transplant Survivor’s Drug Costs Soar After Insurance Denial
Herres received a heart transplant and needs a medicine called everolimus to help protect the donated heart.
Her insurance company stopped paying for the medicine.
After she shared her problem online, the insurance coverage was restored.
However, the medicine then cost her $1,000 for a 90-day supply instead of $180.
Her story spread widely on social media.
Mary Cutter, whose son donated the heart, offered to help pay for the drug.
Mark Cuban saw the story and helped arrange a lower-cost supply through his pharmacy.
A nonprofit connected to Claimable is paying that cost, which is about $300 for 90 days.
The case highlights how insurance denials can make necessary medical care unaffordable.
Elevance Health stopped covering heart-transplant survivor Herres’ everolimus last year.
Her 90-day supply rose from $180 to $1,000 after coverage was restored.
Her social-media posts went viral, drawing help from Mary Cutter and Mark Cuban.
Cuban’s pharmacy began supplying the medicine for about $300 per 90 days.
Studies show insurance denials are affecting access to medicines and recommended care.
- Who
- Herres, an unnamed 26-year-old heart-transplant survivor; Elevance Health; Mary Cutter; Mark Cuban; and a nonprofit linked to Claimable.
- What
- Her insurance initially denied coverage for everolimus, causing the price of a 90-day supply to rise from $180 to $1,000.
- Where
- The article discusses the case in the context of the United States healthcare and insurance system.
- When
- The coverage decision occurred last year; the insurance coverage was restored the day after Herres shared her situation online.
- Why
- Elevance Health said the denials did not fully account for Herres’ treatment history and that everolimus is a more expensive specialty medicine.
Patient and Access Concerns
Insurer Explanation
Whether coverage was meaningful
Patient and Access Concerns
Herres said the restored approval was effectively a 'ghost approval' because the $1,000 price made the medicine financially impossible to obtain.
Insurer Explanation
Elevance Health restored coverage but described everolimus as a specialty medicine that costs more.
Reason for the denial
Patient and Access Concerns
Herres’ experience suggests that the insurer’s decision did not adequately account for her transplant treatment and ongoing need for the drug.
Insurer Explanation
Elevance Health said the denials did not fully account for Herres’ treatment history with everolimus.
How patients should respond
Patient and Access Concerns
Patients may need appeals, external reviews, state complaints, or financial assistance when coverage decisions leave essential treatment unaffordable.
Insurer Explanation
Insurers can deny claims for reasons including billing mistakes, administrative problems, lack of medical necessity, or out-of-network treatment.
Key facts
- Patient
- Herres is a 26-year-old heart-transplant survivor.
- Medicine
- Everolimus, which Herres needs after her heart transplant.
- Original cost
- $180 for a 90-day supply.
- Post-restoration cost
- $1,000 for the same 90-day supply.
- Cuban-supported cost
- About $300 for 90 days through Mark Cuban’s pharmacy.
- Insurance denial data
- IQVIA found that 70% of commercially insured patients were initially denied coverage for at least one newly prescribed branded medicine in 2024.
- Medical-care denial data
- A Commonwealth Fund study found that 21% of US working-age adults with private insurance said they or a family member had been denied doctor-recommended care.
Quotes
Mark Cuban
Investor and owner of the Dallas Mavericks
“I call that ghost approval. Technically, you approved it, but I still can't realistically get the med because you made it financially impossible to get.”
businesstoday.in
“This is beyond incredible. Approve and pay for the heart transplant. Deny the generic rejection medicine.”
businesstoday.in
Sources
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