An alarming new IQVIA study found that Medicare Part D plans routinely deny access to prescribed medicines for patients with newly diagnosed chronic conditions. More than 70% of patients faced an initial immediate denial for their medicines in four of the five chronic therapeutic areas studied. Pharmacy benefit managers (PBMs) and plans increasingly use aggressive tactics to deny coverage, such as excluding physician-prescribed medicines from coverage and imposing inappropriate prior authorization and fail-first requirement barriers.
PBMs deny patients coverage for medicines they need.
More than half of patients in this study faced an initial denial of coverage when attempting to fill a new prescription.
- Over 70% of patients were initially denied in four of the five therapeutic areas.
- On average, patients faced two to three rejections before gaining approval for their medicine. However, some had to overcome a staggering 11 or more rejections.
This increase in rejections is likely due to PBMs and Part D plans steadily imposing restrictions on which medicines are covered and how patients can access that coverage. A Health Affairs study found that the number of medicines excluded from coverage skyrocketed from 20% in 2011 to more than 30% in 2020 (outside the six protected classes). Unfortunately, the IQVIA study revealed that patients initially rejected due to their medicine being excluded from their coverage had a more difficult time overcoming a denial, although not entirely impossible.
However, patients who didn’t balk at payers’ initial “no” and managed to navigate their way through the onerous system to get approval experienced an average delay in accessing their medicine of two to three weeks. Between 10% and 19% of these patients encountered even longer delays, lasting five weeks or more.
Even after a year, up to 42% of patients failed to get their new prescription.
While some patients successfully fought plan rejections to gain access to new medicines, many failed or encountered obstacles that left them without crucial treatments. After one year, up to 42% of new patients remained in limbo and had still not received approval for their initially prescribed treatment. Of patients who didn’t receive approval for their initial medicine after a year, up to 80% of them were unable to initiate any new treatment for their condition.
To address the access challenges for patients with chronic diseases, the Centers for Medicare and Medicaid Services (CMS) needs to improve data reporting and enforce stricter oversight on formularies.
Without reform, plans and PBMs are free to continue these abusive practices, leaving patients to navigate an increasingly complex and costly system to get their medicines. It’s time for Congress to pass reform and increase transparency into the many ways PBMs game the system.
Caroline Dunne
Caroline Dunne serves as a Director of Public Affairs at PhRMA, where she leads communications strategies and initiatives for the organization's cost and value priorities. She brings extensive experience in advocacy strategy, with a background that spans gubernatorial and presidential politics. Caroline is passionate about contributing to an industry whose innovations have had a meaningful impact on her family's life.