Commercial insurers initially denied coverage for three out of four patients’ newly prescribed medicines in five chronic disease areas studied by IQVIA in a new white paper.
Why it matters: By denying these doctor-prescribed medications, insurers and pharmacy benefit managers (PBMs) are choosing to maximize profits over patients. Initial coverage denials are so common that being approved at the outset for these treatments without encountering barriers was as likely as meeting someone who doesn’t own a smartphone or computer. More than 90% of patients faced denials in four of the five therapeutic areas studied.
More delays: Patients who were initially denied coverage but eventually were able to fill their new prescription faced an average coverage delay of three to five weeks.
- 17% – 31% of patients experienced a coverage delay of 5+ weeks, depending on the therapeutic area.
- 2 – 4 rejections were typical before approval. However, some patients faced 11+ rejections before accessing the medicine prescribed by their doctors.
More barriers: PBMs and insurers control benefits through processes like prior authorization, embedded step therapy, and formulary controls that may allow PBMs and insurers to deny coverage or push patients to alternative treatments from the initially prescribed medicine.
- Up to 67% of patients in the study could not fill their new prescription within a year.
- 64% – 82% of those who failed to overcome the denial did not fill any new prescription altogether after one year.
Bottom line: Without reform, insurers and PBMs will continue to get in-between patients and their medicines. Patients may experience long delays before approval of their prescribed medicines, if they can access them at all. These delays may be unacceptable for patients fighting serious diseases that need quick treatment to improve or save their lives.
It’s time for Congress to pass PBM reform. Learn more at PhRMA.org/PBMs.
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.