PHILADELPHIA—Patients with blood cancers often face major insurance hurdles and significant out-of-pocket costs when trying to access specialty oral anticancer medications, according to a new nationwide study led by researchers at the Perelman School of Medicine at the University of Pennsylvania.
Specialty oral anticancer medications, including innovative targeted therapies, have transformed treatment for leukemias, lymphomas, and multiple myeloma by offering highly-effective options that patients can take at home. Because these drugs are typically covered under pharmacy benefits—the part of insurance that pays for prescription drugs—patients may face approval requirements and high cost-sharing before treatment begins.
To examine these barriers, researchers tracked oral blood cancer drug prescriptions from their initial pharmacy submission through insurer approval and whether patients filled them within 90 days. The nationwide claims analysis included more than 12,000 Medicare and commercially insured patients who were newly prescribed these drugs in 2022.
“These blood cancer medications can be life-prolonging, but our findings show that insurance coverage requirements and high out-of-pocket costs can delay or limit access,” said Jalpa A. Doshi , PhD, senior author of the study, Leon Hess Professor of Internal Medicine, and senior fellow at the Leonard Davis Institute of Health Economics. “This national benchmark helps identify where patients encounter barriers along the prescription pathway.”
At the first pharmacy submission, 64.9 percent of prescriptions for Medicare patients and 84 percent for commercially insured patients were rejected. Within 90 days, insurer approval rates had risen to 85 percent for Medicare patients and 62.9 percent for commercially insured patients.
The most common reasons for rejection included prior authorization and drugs not being covered by a patient’s insurance plan. Among Medicare patients, 32.1 percent of prescriptions were initially rejected because prior authorization was required, but only 4.6 percent remained rejected for that reason by 90 days. Among commercially insured patients, 27.8 percent were initially rejected due to prior authorization and 17.1 percent because the drug was not covered by the plan. By 90 days, those rates had fallen to 6.9 percent and 8.0 percent, respectively.
The researchers could not determine whether individual rejections were clinically appropriate. The results nevertheless suggest that prior authorization may impose avoidable work and treatment delays in cases where insurers ultimately approve the prescribed therapy.
Even after receiving insurer approval, many patients did not fill their prescriptions within 90 days. Overall, 54.5 percent of Medicare patients and 45.5 percent of commercially insured patients had a prescription that was both approved and filled during that period.
Among approved prescriptions, fill rates were lower when patients faced higher out-of-pocket costs. For Medicare patients, fill rates were 84.9 percent when costs were $15 or less and 76.7 percent when costs were between $15.01 and $175, compared with 38 percent for costs between $175.01 and $500 and 29.2 percent for costs between $500.01 and $2,000. Among commercially insured patients, fill rates were 80 percent when costs were $15 or less and 71.3 percent when costs were between $15.01 and $175, compared with 30.9 percent for costs between $500.01 and $2,000 and 21.6 percent when costs exceeded $2,000.
“Getting an insurer to approve a cancer drug is only the first hurdle,” Doshi said. “We saw a second drop-off at the pharmacy counter when patients faced high out-of-pocket costs. For Medicare beneficiaries, the new annual out-of-pocket cost cap and Medicare Prescription Payment Plan option may help patients spread high prescription costs over the year. But awareness and enrollment will be critical if patients are going to benefit.”
The findings also raise questions about whether similar approaches could help commercially insured patients, who experienced higher insurance rejection rates and fewer final approvals than Medicare patients. The authors note that changes to prior authorization, drug coverage rules, and cost-sharing may be needed to help ensure patients’ ability to get oral cancer drugs is not shaped by differences in insurance plan design.
The research was funded by Blood Cancer United, formerly the Leukemia & Lymphoma Society.
The study was conducted in collaboration with researchers from MD Anderson Cancer Center, Yale University, and Columbia University.
Editor’s note: Doshi reports grants from Janssen and consulting for AbbVie and Merck.
Journal of Clinical Oncology