Insurers reject up to one-third of new specialty oral blood cancer prescriptions
Key takeaways:
- Insurers reject one-third of new prescriptions for specialty oral medications for blood cancers.
- Likelihood of initial rejection varied based on insurance type.
SAN DIEGO — Insurers rejected one-third of new prescriptions for specialty oral anticancer medications ordered for patients with blood cancers, according to retrospective data presented at ASH Annual Meeting and Exposition.
Patients with commercial insurance and Medicaid had prescriptions rejected more often than patients with Medicare.
“When the new high-cost cholesterol-lowering medications came on the market around 2016, we started looking at insurance rejection rates because we were hearing from our cardiology colleagues that it had been really difficult to get patients access to these medications — particularly patients who were truly in high need,” Jalpa A. Doshi, PhD, Leon Hess professor of internal medicine at University of Pennsylvania’s Perelman School of Medicine, told Healio.
Doshi said she was surprised to see a similar striking trend in oncology.
“I’ve done studies across a series of different disease areas, but I went into this study thinking, ‘This is cancer. It’s different,’” Doshi said. “You wouldn’t think the number of rejections here would be high, especially with a lot of the treatments being National Comprehensive Cancer Network guideline-based treatments. Yet, we found that about one in three prescriptions were being rejected.”
Background and methodology
Multiple specialty oral anticancer medications (SOAMs) are available for treatment of leukemia, lymphoma and multiple myeloma.
However, unlike traditional chemotherapies, the prices of these agents often are high and patients typically remain on treatment for long periods.
U.S. insurance companies often restrict formulary coverage for SOAMs with strict prior authorization requirements and step therapy policies that delay treatment initiation or force treatment plan changes.
Doshi and colleagues used prescription and medical claims from the 2021 to 2023 Symphony Health Solutions Integrated Dataverse database to estimate rates of and reasons for insurer rejection for patients with blood cancers. Investigators analyzed outcomes overall and by patients’ insurance type.
The analysis included nearly 14,000 patients (mean age, 65.7 years; 54% men; 61% white) who had at least one new SOAM prescription for any blood cancer during 2022. More than half (58.2%) of patients had Medicare, 36.3% had commercial insurance and 5.5% had Medicaid.
SOAM prescription rejection and the reason for rejections served as key outcomes.
Results, next steps
One-third (34%) of the patients newly prescribed an SOAM had their initial prescription rejected by the insurer.
The most common reasons for rejection included pharmacy not in network (30%), prior authorization requirements (20%), and lack of formulary coverage (11%).
Initial rejection rates were considerably higher for patients with commercial insurance (47%) or Medicaid (45%) than Medicare (25%).
Rejections due to prior authorization requirements occurred more frequently for patients with Medicare, whereas rejections due to lack of formulary coverage occurred more frequently among those with commercial insurance.
Compared with patients with Medicare insurance, those with commercial insurance (OR = 2.92; 95% CI, 2.2-3.86) and those with Medicaid (OR = 2.33; 95% CI, 1.61-3.36) had significantly higher odds of prescription rejections.
Additional analyses focused on patients whose prescriptions were initially rejected because prior authorization was required; only a small proportion of these patients had a second attempt and ultimately received approval across all insurance types.
“In the context of cancer, I feel like an initial rejection rate this high is basically putting these patients — who are already undergoing the stress and anxiety of having a new diagnosis and are now being told that their prescription is being rejected by the insurer — under even more stress,” Doshi told Healio. “Our results suggest a few areas of further investigation into the appropriateness of these rejections, eventual fill rates and patient outcomes, and, if needed, legislative efforts to facilitate appropriate, timely access to these medications.
“In the meantime, real-time benefit tools could play an expanded role in oncology practice by providing more information at the point of prescribing, including details on formulary coverage, prior authorization requirements, and pharmacy restrictions in addition to the out-of-pocket costs under the patient’s plan,” she added.
For more information:
Jalpa A. Doshi, PhD, can be reached at jdoshi@pennmedicine.upenn.edu.
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Doshi JA, et al. Abstract 786. Presented at: ASH Annual Meeting and Exhibition; Dec. 7-10, 2024; San Diego.