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Prescription Rejections for Specialty Oral Anticancer Medications

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A recent study published in the Journal of Clinical Oncology reveals that insurers initially reject a significant number of new prescriptions for specialty oral anticancer medications (SOAMs) targeting blood cancers, impacting both Medicare and commercially insured patients.

This analysis, covering July 1, 2021, to March 31, 2023, delved into claims data from Symphony Health Solutions, involving 12,134 patients prescribed FDA-approved SOAMs for leukemia, lymphoma, or myeloma. The study reported that insurers initially rejected 64.9% of prescriptions for Medicare beneficiaries and 84.0% of those for commercially insured patients. High out-of-pocket costs further deterred patients from filling prescriptions, with fill rates declining significantly when costs exceeded $175.

Initial Rejections and Implications

The study highlights the role of prior authorization and formulary restrictions as primary reasons for initial rejections. These barriers delay treatment access, ultimately impacting patient outcomes. Jalpa A. Doshi, PhD, from the University of Pennsylvania, pointed out that insurance approval is merely the first hurdle. High out-of-pocket costs further impede access to necessary medications. Notably, prior authorization issues accounted for 32.1% of Medicare rejections and 27.8% of those for commercially insured patients.

Comparison of Medicare and Commercial Insurance

Patients with commercial insurance faced higher rejection rates compared to Medicare beneficiaries, partly due to Medicare Part D's mandate to cover nearly all drugs in certain protected classes, including oncology medications. By the end of the study, 30.5% of Medicare patients and 17.4% of commercially insured patients had not filled their approved prescriptions. On average, Medicare patients faced an out-of-pocket expense of $933 per initial prescription, while commercially insured patients faced $775.

Key Findings

  • Initial rejection rates for SOAMs: 64.9% for Medicare, 84.0% for commercial insurance.
  • Revised approval and fill rates at 90 days: 54.5% (Medicare), 45.5% (commercial).
  • High out-of-pocket costs causing significant declines in fill rates.
  • Prior authorization rejections: 32.1% (Medicare), 27.8% (commercial).
  • Average out-of-pocket expense: $933 (Medicare), $775 (commercial).

Impact of Recently Passed Legislation

The Inflation Reduction Act recently introduced provisions affecting Medicare patients, such as capping annual out-of-pocket costs. These changes are expected to improve prescription fill rates. For Medicare patients, reduced out-of-pocket costs of $175 or less correlated with higher fill rates, although awareness of these cost-saving measures remains limited.

Industry Context and Future Considerations

The study underscores the critical need for streamlining processes like prior authorization, which, although often overturned, creates administrative burdens that delay patient access to life-extending medications. Leveraging electronic prior authorization tools and policies designed for efficient approval of high-performing prescribers could mitigate these challenges. While the effects of recent legislative changes on out-of-pocket costs are promising, industry professionals need to ensure widespread awareness and participation in such programs to maximize their utility.