Insurance Restrictions and High Costs Limit Blood Cancer Treatment Access

Key Takeaways

• A nationwide study of 12 134 patients found that most specialty oral anticancer medication (SOAM) prescriptions for blood cancers were initially rejected by insurers, particularly among commercially insured patients.
• Within 90 days, only 54.5% of Medicare beneficiaries and 45.5% of commercially insured patients received approval and filled their prescriptions.
• Higher out-of-pocket (OOP) costs were associated with substantially lower prescription fill rates, highlighting persistent affordability barriers.

A nationwide US study published in the Journal of Clinical Oncology found substantial insurance and affordability barriers to SOAMs for patients with blood cancers. Researchers found that most prescriptions were initially rejected by insurers, and many remained unfilled even after approval.

Insurance Rejections and Prescription Fill Rates

Researchers analyzed nationwide claims data from 12 134 patients who received at least 1 new SOAM prescription in 2022. Medicare beneficiaries represented 61.0% of the study population, while commercially insured patients accounted for 39.0%.

At initial submission, insurers rejected 64.9% of prescriptions for Medicare beneficiaries and 84.0% for commercially insured patients, frequently because of prior authorization or formulary restrictions. Only 9.6% of Medicare prescriptions and 4.0% of commercial prescriptions were initially approved and filled.

Within 90 days, approval rates increased to 85.0% for Medicare patients and 62.8% for commercially insured patients. However, only 54.5% and 45.5%, respectively, ultimately received approval and filled their prescriptions.

Financial barriers also influenced prescription fulfillment. Fill rates declined substantially when OOP costs exceeded $175, reaching 29.2% among Medicare patients facing costs of $500.01 to $2000 and 21.6% among commercially insured patients facing costs of $2000 or more.

Mean OOP costs for approved prescriptions were $933 among Medicare beneficiaries and $775 among commercially insured patients. Approximately 1 in 5 patients faced costs exceeding $2000 for a single prescription.

Implications for Oncology Treatment Access

The findings demonstrate how insurance restrictions and medication affordability may complicate access to oral cancer therapies.

Researchers reported that 77% of initially rejected prescriptions were eventually approved within 90 days, raising questions about the administrative burden associated with prior authorization requirements.

Commercially insured patients experienced substantially greater barriers, with adjusted analyses showing approximately 3 times the odds of rejection and more than 8 times the odds of rejection due to formulary exclusion compared with Medicare beneficiaries.

Potential solutions discussed by the researchers include electronic prior authorization tools, exemptions for qualifying prescribers, and expanded financial assistance.

Medicare Part D reforms may also help address affordability. The 2026 annual OOP maximum of $2100 and Medicare Prescription Payment Plan could reduce immediate financial burdens by distributing costs across monthly payments.

However, researchers noted that awareness and enrollment in the payment program remain limited.

Researchers Highlight Opportunities for Reform

The researchers emphasized the need to address administrative and financial barriers to treatment access.

“Our findings support ongoing efforts by ASCO and the American Society of Hematology (ASH) to reform the PA process to reduce administrative burden and ensure timely patient access to cancer therapies,” wrote the authors.

The researchers also highlighted electronic prior authorization tools and financial assistance strategies as potential approaches to improving access.

The study underscores persistent barriers to SOAM access in the United States, particularly among commercially insured patients. The authors called for further investigation into the clinical consequences of treatment delays and noninitiation, alongside evaluations of policy reforms intended to improve equitable access to oral cancer therapies.

Reference

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. 2026. doi:10.1200/JCO-26-00247