Commercial insurers initially rejected 84% of new specialty oral blood cancer drug prescriptions, while Medicare plans rejected 64.9%, according to a study published Sept. 30 in the Journal of Clinical Oncology.
Researchers from Philadelphia-based University of Pennsylvania analyzed prescription and medical claims data from July 1, 2021, to March 31, 2023, for 12,134 Medicare and commercially insured patients to evaluate how often new specialty oral blood cancer drug prescriptions were rejected, approved and ultimately filled.
Here are six notes from the study:
- At first submission, only 9.6% of Medicare prescriptions and 4% of commercial prescriptions were approved and filled.
- Insurers initially rejected 32.1% of Medicare prescriptions and 27.8% of commercial prescriptions because they required prior authorization, the most common reason for rejection. Another 17.1% of commercial prescriptions were initially rejected because the drug was not on the plan’s formulary.
- Within 90 days of first submission, 85% of all Medicare prescriptions and 62.8% of all commercial prescriptions had been approved, and 77% of initially rejected prescriptions had been approved.
- Despite approval, 30.5% of Medicare patients and 17.4% of commercially insured patients never filled their prescriptions within 90 days.
- In total, 54.5% of Medicare patients and 45.5% of commercially insured patients received approval and filled their prescriptions.
- Patients were less likely to fill approved prescriptions that cost more than $175 out of pocket.
Among Medicare patients, 76.7% filled prescriptions if costs ranged from $15.01 to $175, compared with 38% at $175.01 to $500 and 29.2% at $500.01 to $2,000.
Among commercially insured patients, the fill rate fell to 21.6% for prescriptions that cost more than $2,000. - The researchers said the Medicare Prescription Payment Plan, which lets Part D beneficiaries spread out-of-pocket costs into monthly payments, could improve access. Under the 2026 annual cap of $2,100, those payments would total $175 a month.
Read the full study here.
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