Journal of clinical oncology : official journal of the American Society of Clinical Oncology · 2026
Insurance and Cost-Related Access Barriers to Specialty Oral Anticancer Medications for Blood Cancers in a Nationwide Sample of Medicare and Commercially Insured Patients.
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Doshi Jalpa A, Li Pengxiang, Geng Zhi, Klebanoff Matthew J, Pettit Amy R, Armstrong Katrina A, Huntington Scott F, Lin John K
Аннотация
PURPOSE: Specialty oral anticancer medications (SOAMs) improve survival across blood cancers, but access challenges persist. This study examined approval and fill rates of SOAM prescriptions indicated for blood cancers in a nationwide sample of Medicare and commercially insured patients.
METHODS: Using nationwide claims, we identified patients with ≥1 new SOAM prescription during 2022. Outcomes included whether a prescription for a new SOAM was (1) rejected by the insurer, (2) approved but not filled by the patient, or (3) approved and filled, at both initial presentation and within 90 days. Among rejected prescriptions, we examined rejection reasons. Among approved prescriptions, we compared fill rates across out-of-pocket (OOP) cost levels. Adjusted outcomes were estimated using logistic regressions.
RESULTS: The study included 12,134 patients (61.0% Medicare, 39.0% commercial) with an SOAM prescription. Initially, very few prescriptions were both approved and filled (9.6%, Medicare; 4.0%, commercial). Insurers initially rejected most prescriptions (64.9% for Medicare, 84.0% for commercial), frequently due to prior authorization or formulary restrictions. By 90 days, approval rates rose to 85.0% (Medicare) and 62.8% (commercial), but many approved prescriptions were never filled; ultimately, only 54.5% of Medicare patients and 45.5% of commercial patients both received insurer approval and filled their prescription. Fill rates dropped sharply when OOP costs exceeded $175 in US dollars (USD), with the lowest rates observed at OOP costs of $500.01-$2,000 USD for Medicare patients (29.2%) and at ≥$2,000 USD for commercially insured patients (21.6%). Adjusted rates were similar to unadjusted rates.
CONCLUSION: This study found substantial access barriers to SOAMs, particularly among commercially insured patients. Even after insurer approval, many patients never filled their prescription. This highlights the importance of addressing both payer-level restrictions and patient-level affordability challenges to ensure treatment access.
METHODS: Using nationwide claims, we identified patients with ≥1 new SOAM prescription during 2022. Outcomes included whether a prescription for a new SOAM was (1) rejected by the insurer, (2) approved but not filled by the patient, or (3) approved and filled, at both initial presentation and within 90 days. Among rejected prescriptions, we examined rejection reasons. Among approved prescriptions, we compared fill rates across out-of-pocket (OOP) cost levels. Adjusted outcomes were estimated using logistic regressions.
RESULTS: The study included 12,134 patients (61.0% Medicare, 39.0% commercial) with an SOAM prescription. Initially, very few prescriptions were both approved and filled (9.6%, Medicare; 4.0%, commercial). Insurers initially rejected most prescriptions (64.9% for Medicare, 84.0% for commercial), frequently due to prior authorization or formulary restrictions. By 90 days, approval rates rose to 85.0% (Medicare) and 62.8% (commercial), but many approved prescriptions were never filled; ultimately, only 54.5% of Medicare patients and 45.5% of commercial patients both received insurer approval and filled their prescription. Fill rates dropped sharply when OOP costs exceeded $175 in US dollars (USD), with the lowest rates observed at OOP costs of $500.01-$2,000 USD for Medicare patients (29.2%) and at ≥$2,000 USD for commercially insured patients (21.6%). Adjusted rates were similar to unadjusted rates.
CONCLUSION: This study found substantial access barriers to SOAMs, particularly among commercially insured patients. Even after insurer approval, many patients never filled their prescription. This highlights the importance of addressing both payer-level restrictions and patient-level affordability challenges to ensure treatment access.