INSURANCE DENIALS AND DISCONTINUATION OF GLUCAGON-LIKE PEPTIDE 1 RECEPTOR AGONISTS IN THE UNITED STATES
Author(s)
Joseph F. Levy, PhD1, Minji Kim, PharmD, ScM2, Emaan Rashidi, MHS2, So-Yeon Kang, PhD, MBA, MPH3, Caleb Alexander, MD, MS4;
1Johns Hopkins University, Baltimore, MD, USA, 2Johns Hopkins Bloomberg School of Public Health, BALTIMORE, MD, USA, 3Georgetown University School of Health, Washington, District of Columbia, DC, USA, 4Johns Hopkins University Bloomberg School of Public Health, BALTIMORE, MD, USA
1Johns Hopkins University, Baltimore, MD, USA, 2Johns Hopkins Bloomberg School of Public Health, BALTIMORE, MD, USA, 3Georgetown University School of Health, Washington, District of Columbia, DC, USA, 4Johns Hopkins University Bloomberg School of Public Health, BALTIMORE, MD, USA
OBJECTIVES: To characterize insurance denial patterns for GLP-1 RAs and assess how formulary management, out-of-pocket (OOP) costs, and patient- and payer-level factors are associated with treatment discontinuation in the United States from 2017 to 2024.
METHODS: We conducted a retrospective cohort study using a 10% person-level sample from IQVIA’s Formulary Impact Analyzer, a nationwide, all-payer pharmacy claims database capturing paid, rejected (prescriptions submitted but not filled, with rejection reasons), reversed (dispensed but not picked up), and cash transactions, covering approximately 63% of U.S. retail pharmacies. We estimated adjusted probabilities of claim rejection using multivariable logistic regression, and assessed factors associated with discontinuation using Cox proportional hazards models.
RESULTS: Among 842,027 individuals who attempted to fill a GLP-1 RA, 73.9% ultimately initiated therapy. On the index fill attempt date, 57.2% initiated via a paid claim, 17.7% had reversed claims, and 25.1% were rejected, most commonly due to utilization management (UM) requirements. Among index rejections, 36.5% were later filled after a median of 64 days (IQR: 22-247 days). A small proportion (1.7%) of initiators used cash at their first fill. Of 622,204 GLP-1 RA initiators, 70.3% discontinued within one year (95% CI: 70.2-70.4). Strong predictors of discontinuation included absence of diabetes evidence, younger age, prior cash use, and experiencing a rejection or reversal on the last claim. Individuals without diabetes evidence and those enrolled in commercial plans faced higher OOP costs than their counterparts.
CONCLUSIONS: One in four patients experienced an insurance rejection at treatment start. While UM was the leading driver of rejection, formulary non-coverage showed a stronger association with treatment discontinuation than clinical or administrative restrictions. Rejection was most common in Exchange plans, followed by Medicaid and commercial insurance. Higher OOP exposure was associated with claim reversal and non-initiation, but payer type was not independently associated with discontinuation among those who successfully initiated therapy.
METHODS: We conducted a retrospective cohort study using a 10% person-level sample from IQVIA’s Formulary Impact Analyzer, a nationwide, all-payer pharmacy claims database capturing paid, rejected (prescriptions submitted but not filled, with rejection reasons), reversed (dispensed but not picked up), and cash transactions, covering approximately 63% of U.S. retail pharmacies. We estimated adjusted probabilities of claim rejection using multivariable logistic regression, and assessed factors associated with discontinuation using Cox proportional hazards models.
RESULTS: Among 842,027 individuals who attempted to fill a GLP-1 RA, 73.9% ultimately initiated therapy. On the index fill attempt date, 57.2% initiated via a paid claim, 17.7% had reversed claims, and 25.1% were rejected, most commonly due to utilization management (UM) requirements. Among index rejections, 36.5% were later filled after a median of 64 days (IQR: 22-247 days). A small proportion (1.7%) of initiators used cash at their first fill. Of 622,204 GLP-1 RA initiators, 70.3% discontinued within one year (95% CI: 70.2-70.4). Strong predictors of discontinuation included absence of diabetes evidence, younger age, prior cash use, and experiencing a rejection or reversal on the last claim. Individuals without diabetes evidence and those enrolled in commercial plans faced higher OOP costs than their counterparts.
CONCLUSIONS: One in four patients experienced an insurance rejection at treatment start. While UM was the leading driver of rejection, formulary non-coverage showed a stronger association with treatment discontinuation than clinical or administrative restrictions. Rejection was most common in Exchange plans, followed by Medicaid and commercial insurance. Higher OOP exposure was associated with claim reversal and non-initiation, but payer type was not independently associated with discontinuation among those who successfully initiated therapy.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR4
Topic
Health Policy & Regulatory
Disease
SDC: Diabetes/Endocrine/Metabolic Disorders (including obesity)