Most prescriptions for oral blood cancer drugs were rejected the first time they reached the pharmacy, according to a peer-reviewed study of 2022 pharmacy claims. Insurers initially rejected 84% of commercial claims and 64.9% of Medicare claims, researchers led by the University of Pennsylvania reported.
The study, published in the Journal of Clinical Oncology, analyzed claims for more than 12,000 patients newly prescribed specialty oral anticancer drugs, including targeted therapies, for leukemia, lymphoma, and multiple myeloma. Many prescriptions were eventually approved, but a large share of patients still did not get the medicine within 90 days.
For families facing a blood cancer diagnosis, the findings describe two hurdles: getting insurance approval, then affording the copay. "These blood cancer medications can be life-prolonging, but our findings show that insurance coverage requirements and high out-of-pocket costs can delay or limit access," said senior author Jalpa Doshi, PhD, a professor at Penn's Perelman School of Medicine, according to News-Medical.
Two Hurdles Before the First Dose
Prior authorization was a leading reason for first rejections. It accounted for 32.1% of Medicare claims and 27.8% of commercial claims at first submission, according to the Penn Medicine release. For commercial claims, another 17.1% were rejected because the plan did not cover the drug.
Many of those problems were resolved. By day 90, prior authorization rejections had dropped to 4.6% for Medicare and 6.9% for commercial claims. Overall, 85% of Medicare prescriptions and 62.9% of commercial prescriptions were approved within 90 days.
But approval did not always mean treatment. Only 54.5% of Medicare patients and 45.5% of commercial patients were both approved and filled the prescription within 90 days. "Getting an insurer to approve a cancer drug is only the first hurdle. We saw a second drop-off at the pharmacy counter when patients faced high out-of-pocket costs," Doshi said.
Cost made a sharp difference. Among Medicare patients with approved prescriptions, 84.9% filled them when they owed $15 or less, but only 29.2% filled them when they owed $500 to $2,000. Among commercial patients facing more than $2,000, just 21.6% filled the prescription.
Prior Authorization Explained
Prior authorization requires a doctor to get insurer approval before a drug is covered. Insurers say it controls costs and ensures appropriate use. For specialty cancer drugs, which can cost thousands of dollars a month, the process often involves forms, test results, and sometimes appeals.
Oral targeted therapies have changed blood cancer care. Pills taken at home now treat conditions such as chronic lymphocytic leukemia and multiple myeloma. But because they are dispensed through pharmacy benefits rather than given in a clinic, patients often face separate approval rules and higher cost-sharing than for drugs infused in a hospital.
Physicians report that the process takes a toll. In the American Medical Association's 2025 prior authorization survey, 95% of doctors reported care delays, and 79% said prior authorization can at least sometimes lead patients to abandon treatment.
Federal reform leaves a gap. A CMS rule finalized in 2024 sets decision deadlines for many prior authorization requests, but "this provision does not apply to prior authorization decisions for drugs," the agency said. Oral cancer drugs fall outside those deadlines.
Limits of the Claims Data
Pharmacy claims show what happened but not why. Claims data cannot show whether individual rejections were clinically appropriate, and they do not capture whether patients later got the drug through free-drug programs or other channels.
The data are also from 2022. Since then, Medicare has capped annual out-of-pocket drug costs, at $2,000 in 2025 and $2,100 in 2026, and created a payment plan that spreads costs across the year. Those changes may have improved affordability for Medicare patients, though the study cannot measure their effect. Commercial plans are not covered by those Medicare protections.
The study was funded by Blood Cancer United, formerly the Leukemia & Lymphoma Society. Doshi reported grants from Janssen and consulting work for AbbVie and Merck, according to the release. Key findings were presented at a medical meeting earlier this year, and the journal paper is the full peer-reviewed version.
Getting Help With Coverage and Cost
Patients prescribed an oral cancer drug can ask their oncology team whether prior authorization is needed and who will handle it. Many cancer centers have pharmacists or financial counselors who track approvals. Asking for the status a few days after a prescription is sent can prevent long delays.
If a claim is denied, patients and doctors can appeal. Patients can ask for the denial reason in writing, since appeals often succeed when doctors supply missing information.
For high copays, patients can ask about manufacturer assistance programs, nonprofit foundations, and specialty pharmacy support. Medicare patients can ask about the Medicare Prescription Payment Plan, which spreads drug costs across the calendar year.
Patients should not skip or delay treatment without talking with their oncologist, and they should speak up early if cost is the barrier. Doctors can sometimes choose a different drug in the same class that a plan covers, or request an exception. People shopping for coverage during open enrollment can check how a plan treats specialty drugs before choosing it, since cost-sharing can vary widely.
Key Questions Answered
What did the study find? Insurers first rejected 84% of commercial and 64.9% of Medicare claims for new oral blood cancer drugs in 2022.
Were most eventually approved? Within 90 days, 85% of Medicare and 62.9% of commercial prescriptions were approved.
How many patients actually got the drug? About 54.5% of Medicare and 45.5% of commercial patients were approved and filled the prescription within 90 days.
How did cost affect filling prescriptions? Fill rates dropped sharply when patients owed hundreds or thousands of dollars.
Is the data current? It is from 2022, before Medicare's out-of-pocket cap took effect in 2025.
What can patients do? Ask the care team about prior authorization status, appeal denials, and seek financial assistance programs.
Published by Medicaldaily.com
