Insurance Approval Leaves Gaps in Oral Blood Cancer Treatment Access

Insurance coverage did not reliably translate into access to specialty oral anticancer medications (SOAMs) for patients with blood cancers, according to a nationwide study published in the Journal of Clinical Oncology. Within 90 days, just 54.5% of Medicare patients and 45.5% of commercially insured patients had both insurer approval and a filled prescription for their newly prescribed agent.¹

For pharmacists, the findings highlight a gap between resolving a rejected claim and helping a patient obtain treatment. Prior authorization support addresses one barrier; affordability assessment and follow-up remain necessary after approval.

Following Prescriptions Beyond the First Rejection

Investigators analyzed nationwide pharmacy and medical claims for 12,134 patients with a new prescription in 2022 for an oral anticancer medication approved for a blood cancer indication. Medicare beneficiaries accounted for 61.0% of the sample, and commercially insured patients represented 39.0%. The analysis followed the index medication from its first pharmacy claim through 90 days.¹

Unlike databases limited to dispensed medications, the study’s data captured rejected claims and approved prescriptions that patients did not fill. This allowed investigators to examine where access broke down.

Initially, insurers rejected 64.9% of Medicare prescriptions and 84.0% of commercial prescriptions. Only 9.6% and 4.0%, respectively, were approved and filled at the first submission. By 90 days, approval rates increased to 85.0% for Medicare and 62.8% for commercial coverage, but dispensing lagged behind.¹

At that point, 30.5% of the entire Medicare cohort and 17.4% of the commercial cohort had an approved prescription that remained unfilled. These percentages describe all patients in each insurance group, rather than only those who received approval.¹

Prior Authorization Creates an Early Hurdle

Prior authorization requirements accounted for initial rejection in 32.1% of Medicare patients and 27.8% of commercially insured patients. Among prescriptions initially rejected for this reason, most eventually received approval. Commercial formulary exclusions proved more difficult to overcome: only 48.5% of prescriptions initially rejected as off formulary subsequently received approval.¹

These findings support checking payer requirements when treatment is prescribed. Pharmacists can identify missing authorization documentation and coordinate transfers when a plan requires a designated specialty pharmacy. Tracking unresolved claims also provides an opportunity to alert the oncology team when access remains uncertain.

However, the study could not determine whether individual rejections were clinically appropriate. Its findings should not be interpreted as evidence that every initial rejection represented an unnecessary denial.¹

Affordability Remains a Barrier After Approval

Among approved prescriptions, fill rates fell sharply when out-of-pocket costs exceeded $175. For Medicare patients, 76.7% filled their prescription when costs were $15.01 to $175, compared with 38.0% when costs were $175.01 to $500. Among commercially insured patients, the corresponding rates were 71.3% and 53.8%.¹

Earlier research documented a similar association. A 2018 study found that adjusted abandonment rates for novel oral anticancer prescriptions increased from 10.0% at out-of-pocket costs of $10 or less to 49.4% above $2000.²

For pharmacy teams, an approved claim should prompt a direct affordability conversation. Asking whether the patient can pay the quoted amount provides information that an adjudication status cannot. When cost prevents dispensing, pharmacists can coordinate financial navigation and confirm whether the patient ultimately receives medication.

Applying the Findings Under Today’s Medicare Benefits

The study evaluated 2022 prescriptions, before the current Medicare Part D out-of-pocket cap. In 2026, annual out-of-pocket spending for covered Part D drugs is capped at $2100. After reaching that threshold, beneficiaries have no additional cost sharing for covered Part D medications that year.³

The Medicare Prescription Payment Plan offers another option by spreading out-of-pocket costs across the calendar year. It does not reduce the total amount owed, and monthly bills can vary. Pharmacists should distinguish payment flexibility from financial assistance when discussing the program.⁴

The analysis does not establish whether these newer policies improve treatment initiation. It also excluded Medicaid patients and could miss medication obtained through manufacturer free-drug programs. Clinical outcomes, including survival, were not evaluated.¹

Nevertheless, the findings give pharmacy teams a practical reason to follow prescriptions through dispensing. Documenting an authorization approval closes an administrative task; confirming medication receipt helps establish whether the access problem has actually been resolved.

REFERENCES

1. Doshi JA, Li P, Geng Z, et al. Insurance and cost-related access barriers to specialty oral anticancer medications for blood cancers in a nationwide sample of Medicare and commercially insured patients. J Clin Oncol. Published online September 30, 2026. doi:10.1200/JCO-26-00247

2. Doshi JA, Li P, Huo H, Pettit AR, Armstrong KA. Association of patient out-of-pocket costs with prescription abandonment and delay in fills of novel oral anticancer agents. J Clin Oncol. 2018;36(5):476-482. doi:10.1200/JCO.2017.74.5091

3. Centers for Medicare & Medicaid Services. Final CY 2026 Part D redesign program instructions. April 7, 2025. Accessed October 26, 2026. https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions?

4. Medicare.gov. Will this payment option help me? Accessed October 26, 2026. https://www.medicare.gov/prescription-payment-plan/will-this-help-me