We truly empathize with families who have children dealing with complex medical conditions and rare diseases. Our company, plan sponsors and physicians are often faced with the difficult challenge of how to compassionately support people when proven therapies are not available. The lack of clear clinical options makes these cases even more challenging for all involved.
In the case of the family highlighted in the Wall Street Journal, we conducted a comprehensive review of whether to cover an experimental therapy that is not FDA approved for the treatment of this condition. We decided to cover the therapy under an exception, which provided access to a treatment that would otherwise not be covered. These circumstances are rare and not representative of a typical experience.
In total, we pay 98% of all eligible claims. For the remaining 2%, the majority are instances where the services did not meet the benefit criteria established by the plan sponsor, such as the employer, state or Centers for Medicare & Medicaid Services (CMS). Less than one-half-of-one percent of claims are not approved based on clinical evidence and patient safety.
We recognize there is always opportunity to improve the experience for the people we serve and we learn from situations like these to do just that.
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