TOPLINE

In a nationwide study of more than 12,000 patients with blood cancers, insurers initially rejected most prescriptions for specialty oral anticancer medications. Even after eventual approval, only 55% of Medicare patients and 46% of commercially insured patients filled their prescriptions within 90 days, with fill rates dropping as out-of-pocket costs rose.

METHODOLOGY

• Researchers conducted a retrospective cohort study using nationwide prescription and medical claims from the Symphony Health Solutions Integrated Dataverse. A total of 12,134 patients (61% Medicare, 39% commercially insured) with at least one new specialty oral prescription for leukemias, lymphomas, or myeloma during 2022 were included.
• Outcomes included whether prescriptions were rejected by insurers, approved but not filled by patients, or approved and filled, assessed at initial presentation and within 90 days.
• For rejected prescriptions, the reasons were examined. For approved prescriptions, fill rates were compared across out-of-pocket cost levels (≤$15, $15.01-$175, $175.01-$500, $500.01-$2000, >$2000).
• Adjusted outcomes were estimated using logistic regressions controlling for sociodemographic factors, clinical characteristics (including comorbidities and number of prescriptions filled in the pre-index period), and index prescription characteristics (drug class, month of prescription).

TAKEAWAY

• Initially, very few prescriptions were both approved and filled: 9.6% for Medicare patients and 4% for commercially insured patients.
• By 90 days, approval rates rose to 85% for Medicare and 62.8% for commercially insured patients, but many approved prescriptions remained unfilled. Ultimately, only 54.5% of Medicare patients and 45.5% of commercially insured patients both received approval and filled their prescription.
• Among initially rejected prescriptions, prior authorization was the most common reason (32.1% Medicare, 27.8% commercial), but most prior authorization rejections were later overturned (75.3%-85.9% approval rate for Medicare, 71.3% for commercial).
• Fill rates for approved prescriptions dropped when out-of-pocket costs exceeded $175: Among Medicare patients, fill rates were 76.7% at $15.01-$175, but fell to 38% at $175.01-$500, 29.2% at $500.01-$2000, and 31.2% at >$2000. Among commercially insured patients, fill rates were 71.3% at $15.01-$175, but declined to 53.8% at $175.01-$500, 30.9% at $500.01-$2000, and 21.6% at >$2000.

IN PRACTICE

"These findings reinforce growing calls for reform from professional societies, including ASCO and ASH [American Society of Hematology], to improve utilization management practices and patient affordability to ensure that access to life-saving oral anticancer therapies is not determined by insurance policies," the study authors wrote.

SOURCE

The study, led by Jalpa A. Doshi, PhD, University of Pennsylvania, Philadelphia, was published online on September 30 in Journal of Clinical Oncology.

LIMITATIONS

The study could not determine the appropriateness of insurer rejections, and some may reflect clinically appropriate utilization management. Patients with Medicaid coverage were excluded. Key clinical factors such as disease status, stage, line of therapy, and performance status were unavailable, although models adjusted for comorbidity index and prescription volume as proxies for health status.

DISCLOSURES

The study was supported by Blood Cancer United (formerly Leukemia & Lymphoma Society). One author reported consulting or advisory roles and research funding from pharmaceutical companies including AbbVie, Merck, and Janssen. Another author reported honoraria, consulting or advisory roles, research funding, and travel expenses from multiple pharmaceutical companies including AstraZeneca, BeiGene, Genentech, and AbbVie. Additional author disclosures are reported in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.