Insurance Hurdles and High Costs Impede Access to Oral Blood Cancer Drugs

Insurance-related restrictions and high out-of-pocket (OOP) costs may create substantial barriers to accessing specialty oral anticancer medications (SOAMs) for patients with blood cancers, according to findings from a nationwide analysis published in the Journal of Clinical Oncology.^1,2 Although most initially rejected prescriptions were eventually approved, many approved prescriptions were never filled, particularly when patient OOP costs were high.

The retrospective study evaluated prescription and medical claims for 12,134 patients who received a new SOAM prescription for a blood cancer in 2022. Of these patients, 7398 (61.0%) had Medicare coverage and 4736 (39.0%) had commercial insurance. The analysis used the Symphony Health Solutions Integrated Dataverse, which captures the prescription pathway from an insurer's initial rejection or approval through whether an approved prescription was ultimately filled.

Key Findings

Initial approval and filling were uncommon, occurring for just 9.6% of prescriptions among Medicare patients and 4.0% among commercially insured patients. Initial rejection occurred for 64.9% and 84.0% of prescriptions, respectively.

Within 90 days, however, 85.0% of initially rejected Medicare prescriptions and 62.8% of commercially insured prescriptions were ultimately approved. Despite those approvals, final approved-and-filled rates were 54.5% for Medicare patients and 45.5% for commercially insured patients.

Cost sharing represented another major barrier. Mean OOP costs were $933 for Medicare patients and $775 for commercially insured patients. Among Medicare patients, the fill rate declined from 84.9% when OOP costs were $15 or less to 29.2% when costs were $500.01 to $2000. Among commercially insured patients, fill rates declined from 80.0% to 30.9% across the same cost ranges and fell to 21.6% when OOP costs exceeded $2000.

Variation by drug class was also observed. Among Medicare patients, final approved-and-filled rates ranged from 47.1% for immunomodulators to 73.1% for BCL-2 inhibitors. Among commercially insured patients, rates ranged from 24.6% for Janus kinase (JAK) inhibitors to 66.2% for Bruton tyrosine kinase (BTK) inhibitors.

Prior Authorization Remains a Key Barrier

Prior authorization (PA) was the most common initial rejection reason among Medicare patients, accounting for 32.1% of rejections, while PA accounted for 27.8% among commercially insured patients. Among commercial prescriptions, 17.1% were initially rejected because the medication was not on the formulary.

Many PA-related rejections were eventually overturned. Among Medicare patients, the proportion of final PA rejections fell to 4.6%, while it was 6.9% among commercially insured patients. For initially rejected prescriptions, 71.3% of commercial PA rejections were eventually approved, compared with 48.5% of prescriptions rejected because the medication was not on the formulary.

The study also found evidence of additional administrative burden. Among patients whose PA-rejected prescriptions were not approved within 90 days, a subsequent submission was attempted for 29.6% of Medicare patients and 49.9% of commercially insured patients. Among those subsequent submissions, 76.8% of Medicare and 47.9% of commercial prescriptions ultimately received a final PA rejection.

Implications for Access

As evidenced by the study findings, insurance approval does not necessarily translate into treatment. Nearly one-third of Medicare patients and one-fifth of commercially insured patients with ultimately approved prescriptions did not fill them, while higher OOP costs were associated with substantially lower fill rates.

The authors noted that the study could not determine whether individual insurance rejections were clinically appropriate and did not capture disease status, treatment line, or clinical outcomes. However, the results identify multiple points at which patients can encounter barriers, from PA and formulary restrictions to administrative delays and cost sharing.

“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,” Jalpa A. Doshi, PhD, of the University of Pennsylvania Leonard Davis Institute of Health Economics and study senior author, said in a news release. “This national benchmark helps identify where patients encounter barriers along the prescription pathway.”

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. Insurance barriers limit access to blood cancer drugs. News release. Penn Medicine. September 30, 2026. Accessed October 2, 2026. https://tinyurl.com/ypeascac