A 26-year-old heart transplant survivor found herself in a desperate situation after her insurance company abruptly ceased coverage for a life-saving anti-rejection drug. Payton Herres, who received a heart transplant as a preteen, relies on everolimus, a generic version of Novartis’ Zortress, to protect her transplanted organ.
Insurance Denial and Skyrocketing Costs
Last year, Herres' insurance provider, Elevance Health, informed her that they would no longer cover the critical medication. The denial left Herres with no clear path forward. Prior to the denial, she had paid $180 for a 90-day supply of the drug. After her situation gained initial traction online, her coverage was technically reinstated, but with a devastating catch: the price for the same 90-day supply had ballooned to $1,000.
“I call that ghost approval. Technically, you approved it,” Herres told MarketWatch. “But I still can't realistically get the med because you [made] it financially impossible to get.”
Viral Outcry Reaches Mark Cuban
Herres initially shared her predicament on Facebook, stating, “I didn't know what else to do.” Her post was shared thousands of times, bringing widespread attention to her plight. The story gained further prominence after The Independent reported on Mary Cutter, the mother of the 24-year-old son whose heart was donated to Herres in 2012. Cutter even offered to pay for Herres’ medication herself.
The story eventually went viral across social media platforms, with users tagging prominent figures like Warris Bokhari, CEO of AI startup Claimable, and billionaire investor Mark Cuban.
Cuban's Pharmacy Steps In
Mark Cuban responded to one of Herres’ LinkedIn posts, expressing disbelief at the situation. “This is beyond incredible,” Cuban wrote. “Approve and pay for the heart transplant. Deny the generic rejection medicine.”
Cuban’s Cost Plus Drugs pharmacy swiftly intervened, offering to supply Herres with the everolimus for approximately $300 for a 90-day supply—significantly less than the $1,000 charged by her insurance-approved pharmacy. A nonprofit organization linked to Bokhari’s startup is currently covering this reduced cost, ensuring Herres receives her vital medication.
Wider Implications of Insurance Denials
Herres’ experience highlights a growing concern regarding insurance companies denying coverage for essential medicines and medical care. A recent study by healthcare consulting firm IQVIA revealed that 70% of commercially insured patients in 2024 faced an initial denial for at least one newly prescribed branded medicine. Nearly a quarter of these patients remained without approval after a year.
The issue extends beyond medication. A Commonwealth Fund study indicated that 21% of US working-age adults with private insurance reported being denied doctor-recommended medical care for themselves or a family member. For nearly 70% of those denied, it resulted in increased out-of-pocket expenses.
What Patients Can Do
Insurance companies can deny claims for various reasons, including billing errors, administrative issues, or deeming a treatment not medically necessary. Patients have the right to appeal these denials, first by requesting an internal review from their insurer, and if unsuccessful, by pursuing an external review by a third party.
Before appealing, patients should understand the specific reason for the denial and gather all relevant policy documents. If all appeals fail, filing a complaint with the state insurance commissioner is another recourse. While emergency savings can help cover costs during the appeal process, Herres’ case underscores that for expensive, life-sustaining drugs, personal savings alone may not be sufficient.