A nationwide study of patients with blood cancers found that most prescriptions for specialty oral anticancer medications were initially rejected by insurers, and many patients did not fill their prescriptions even after receiving approval. The findings, reported by Doshi et al in the Journal of Clinical Oncology, identified substantial barriers associated with insurance restrictions and out-of-pocket costs, particularly among commercially insured patients.
Study Details
The investigators conducted a retrospective study using nationwide prescription and medical claims from the Symphony Health Solutions Integrated Dataverse. The analysis included 12,134 patients who received at least one new prescription for a specialty oral anticancer medication indicated for leukemia, lymphoma, or multiple myeloma during 2022. Of these patients, 7,398 (61.0%) had Medicare coverage and 4,736 (39.0%) had commercial insurance.
The researchers examined whether prescriptions were rejected by insurers; approved, but not filled; or approved and filled, both initially and within 90 days. They also evaluated reasons for rejection, including prior authorization requirements and formulary restrictions, and assessed prescription fill rates according to out-of-pocket costs. Logistic regression models adjusted for sociodemographic, clinical, and prescription-related characteristics.
Key Results
At initial submission, 64.9% of prescriptions for Medicare beneficiaries and 84.0% for commercially insured patients were rejected. Only 9.6% and 4.0% of prescriptions, respectively, were both approved and filled initially. By 90 days, approval rates increased to 85.0% for Medicare patients and 62.8% for commercially insured patients. However, only 54.5% and 45.5%, respectively, ultimately received approval and filled their prescriptions.
Prior authorization requirements were a frequent reason for rejection, accounting for initial rejections among 32.1% of Medicare patients and 27.8% of commercially insured patients. By 90 days, 85.0% of Medicare patients and 62.8% of commercially insured patients had received prescription approval. However, 30.5% and 17.4%, respectively, had not filled their approved prescriptions, leaving only 54.5% and 45.5% who had both received approval and filled their prescriptions.
In adjusted analyses, commercially insured patients had significantly greater odds of prescription rejection than Medicare beneficiaries, both initially (odds ratio [OR] = 3.27, 95% confidence interval [CI] = 2.31–4.63; P < .001) and at 90 days (OR = 2.62, 95% CI = 2.07–3.30; P < .001). The adjusted odds of rejection because of formulary exclusion were more than eight times higher among commercially insured patients.
Out-of-pocket costs were strongly associated with prescription abandonment. Mean costs for the first approved prescription were $933 for Medicare patients and $775 for commercially insured patients. Among Medicare beneficiaries, fill rates declined from 84.9% when costs were $15 or less to 38.0% when costs ranged from $175.01 to $500 and 29.2% when costs ranged from $500.01 to $2,000. Among commercially insured patients, fill rates declined from 80.0% at costs of $15 or less to 21.6% when costs exceeded $2,000.
The investigators concluded: “This study found substantial access barriers to [specialty oral anticancer medications], particularly among commercially insured patients. Even after insurer approval, many patients never filled their prescription. This highlights the importance of addressing both payer-level restrictions and patient-level affordability challenges to ensure treatment access.”
Jalpa A. Doshi, PhD, of the University of Pennsylvania, Philadelphia, and the Leonard Davis Institute of Health Economics, Philadelphia, is the corresponding author for the Journal of Clinical Oncology article.
DISCLOSURE: The study was supported by Blood Cancer United (formerly Leukemia & Lymphoma Society). For full disclosures of the study authors, visit ascopubs.org.
