DELAYS AND DENIALS FOR BRANDED MEDICATION FILLS DUE TO PRIOR AUTHORIZATION
Author(s)
Yang Wang, PhD1, Joseph F. Levy, PhD1, Joseph Mattingly II, MBA, PharmD, PhD2, Gerard Anderson, PhD1;
1Johns Hopkins University, Baltimore, MD, USA, 2University of Utah, Park City, UT, USA
1Johns Hopkins University, Baltimore, MD, USA, 2University of Utah, Park City, UT, USA
OBJECTIVES: Prior authorization (PA), a practice used by insurance companies to control care utilization, may create barriers for treatment delivery. Less is known regarding its impact on delaying and denying prescription drug fills. This study examined PA processing time and approval rates for branded medication fills subject to PA reviews, and assessed key factors that drive variation in processing time and approval rates.
METHODS: Using national pharmacy claims data in 2024, this study focused on 205,896 branded drug fills that encountered initial PA rejections. For each fill, PA reviewing time (in days) and final adjudication outcome (approved or denied) were identified. The prevalence of same day processed drug fills and ultimately approved fills were calculated. They were then stratified by number of PA reviews, rejection reasons, refill status, days of supply, prescribers’ ownership, insurance market segment, and patient age, gender, and disease conditions. Logistic regressions were performed to estimate the association between these factors and the likelihood of same day process and final approval.
RESULTS: This study included 205,896 branded drug fills from 156,848 unique patients and 88 branded drug molecules, where 53% were GLP-1 Agonists. 71,324 (35%) prescription fills were processed in 1 day, and the remaining 65% were processed with a median of 6 days. 111,758 (54%) of them were eventually approved. Medication fills with multiple rounds of PA reviews, additional rejection reasons, or refills were associated with 37% (95% CI: 37%-37%), 39% (95% CI: 38%-39%), and 9% (95% CI: 9%-10%) lower probability of same day process, respectively. Medication fills from Medicaid patients or patients with multiple disease conditions had 8% (95% CI: 7%-8%) and 5% (95% CI: 4%-5%) lower approval rates, respectively.
CONCLUSIONS: Most drug fills with initial PA rejections experienced treatment delays or eventual denials. Claim adjudication complexity and patient characteristics were key drivers.
METHODS: Using national pharmacy claims data in 2024, this study focused on 205,896 branded drug fills that encountered initial PA rejections. For each fill, PA reviewing time (in days) and final adjudication outcome (approved or denied) were identified. The prevalence of same day processed drug fills and ultimately approved fills were calculated. They were then stratified by number of PA reviews, rejection reasons, refill status, days of supply, prescribers’ ownership, insurance market segment, and patient age, gender, and disease conditions. Logistic regressions were performed to estimate the association between these factors and the likelihood of same day process and final approval.
RESULTS: This study included 205,896 branded drug fills from 156,848 unique patients and 88 branded drug molecules, where 53% were GLP-1 Agonists. 71,324 (35%) prescription fills were processed in 1 day, and the remaining 65% were processed with a median of 6 days. 111,758 (54%) of them were eventually approved. Medication fills with multiple rounds of PA reviews, additional rejection reasons, or refills were associated with 37% (95% CI: 37%-37%), 39% (95% CI: 38%-39%), and 9% (95% CI: 9%-10%) lower probability of same day process, respectively. Medication fills from Medicaid patients or patients with multiple disease conditions had 8% (95% CI: 7%-8%) and 5% (95% CI: 4%-5%) lower approval rates, respectively.
CONCLUSIONS: Most drug fills with initial PA rejections experienced treatment delays or eventual denials. Claim adjudication complexity and patient characteristics were key drivers.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR107
Topic
Health Policy & Regulatory
Topic Subcategory
Reimbursement & Access Policy
Disease
SDC: Diabetes/Endocrine/Metabolic Disorders (including obesity)