Authored by Brian Koffman, MDCM (retired), MSEd
Bottom Line:
In 2022, a quarter of new prescriptions for specialty oral blood cancer medications were rejected by insurance. Commercial insurers rejected 39%, Medicare 16%, Medicaid 30%.
Who Performed the Research and Where Was it Presented:
Jalpa A. Doshi, PhD of U. of Pennsylvania, on behalf of her colleagues, gave an oral presentation at the American Society for Hematology (ASH) Annual Meeting in 2024.
Background:
Specialty oral anticancer drugs have drastically improved outcomes for leukemia, lymphoma, and myeloma, including chronic lymphocytic leukemia / small lymphocytic lymphoma (CLL / SLL), but they come at considerable cost, and not all patients have access.
These medicines are often very expensive, and many are prescribed for extended periods. To control the high costs, insurers have restricted formulary coverage, instituted laborious and strict prior authorization (PA) procedures, and/or step therapy (ST) policies that can delay the start of treatment or even force changes in the treatment plans.
The real-world magnitude of prescription rejection overall and by insurer type is largely unstudied from the patient’s perspective.
Methods and Participants:
- Nationwide real-world retrospective analysis.
- Prescription and medical claims from Symphony Health Solutions Integrated Dataverse database were interrogated.
- Data included whether a prescription was approved or rejected by the patient’s insurer and the reason for rejection.
- Any patients with one or more prescriptions for any blood cancer in 2022 were included.
- Data were compared for brand-name and generic medications.
Results:
- A total of 15,842 patients were studied, with an average age of 65.4.
- 54.7% were male, 54.8% were white.
- 58.2%, 36.1%, and 5.8% were enrolled in Medicare, commercial insurance, and Medicaid, respectively.
- The initial insurer rejection rate was 25.7% among the 9,272 patients prescribed brand-name only (no generic equivalent available) medications. Still, there was significant variation in rejection rates based on insurance type, with commercial insurance having more than double the rate of Medicare. Rejection rates were
- Medicare: 16.0%
- Commercial insurance: 39.0%
- Medicaid: 29.9%.
- Three out of ten rejections were due to PA/ST requirements.
- One in eight rejections was due to a lack of formulary coverage.
- PA/ST was more likely to be the reason for rejection in Medicare patients.
- Commercial patients were more likely to have a lack of formulary coverage as their reason for rejection.
- Compared to those insured with Medicare, those with commercial insurance had three times the rate of rejection, and those with Medicaid had two times the rate.
- Less than ten percent of the rejected prescriptions were approved within three months for all insurance types.
- 6,570 patients were prescribed an oral blood cancer medication where a generic option was available. Remarkably, rejection rates were even higher and nearly identical between the brand-name and generic.
- The initial rejection rate for the branded drug was 34.2%, and for the generic, it was 35.3%. Medicare patients had by far the lowest rates of rejection.
- Only about one in four initially rejected prescriptions were approved within three months, regardless of insurance type.
Conclusions:
Between one in four and one in three specialty oral blood cancer prescriptions are initially rejected. Even when adjusting for socioeconomic determinants of health and clinical markers and status, the rejection risk was much higher in those with commercial insurance, followed by Medicaid. Medicare had by far the lowest rejection rate at 16%. Generic drugs fared no better. The vast majority of scripts initially rejected were not approved in the next 90 days.
The reasons for the high rate of rejections and the discrepancies in the rates, especially the high rates for those with commercial insurance, need to be investigated and remedied. Patients are too often being denied life-extending medications. This doesn’t even address the likely reality that many prescribers are not even writing scripts for the newer revolutionary medications as they know from experience the high risk of it being denied and the psychological toll that can take on their patients. Patients rightly ask why I am not getting the first-choice medication my doctor wants me to have.
CLL Society will always advocate for improved access to all therapies for all CLL /SLL patients regardless of insurance or socioeconomic status. For one example read: CLL Society Joins Advocates in Warning CMS that “Monitoring” Health Plans’ Efforts to Delay/Deny Needed Prescriptions is Not Enough
Links and Resources:
Listen to Dr. Koffman’s monologue below.
You can read the ASH 2024 abstract: Real-World Analysis of Insurer Rejection Rates for Specialty Oral Anticancer Prescriptions in a Nationwide Sample of Patients with Blood Cancer
For more on Medicare and insurance, we recommend our webinar: Your Medicare Guide: Tackling Costs and Answering Your Questions
