Prior Authorization and Association With Delayed or Discontinued Prescription Fills

Abstract

PURPOSE Prior authorization requirements are increasing but little is known about their effects on access to care. We examined the association of a new prior authorization policy with delayed or discontinued prescription fills for oral anticancer drugs among Medicare Part D beneficiaries. METHODS Using Medicare part D claims data from 2010 to 2020, we studied beneficiaries regularly filling one of 11 oral anticancer drugs, defined as three 30-day fills in 120 days preceding the plan's prior authorization policy change on that drug and continuously enrolled in the same plan for 120 days before and after the policy change at the start of a new year. The control group consisted of beneficiaries meeting the same utilization criteria, but who were enrolled in plans at the same time that did not implement a prior authorization policy change. The outcomes of interest were discontinuation of the drug within 120 days (analyzed with regression analyses) and time (in days) to next fill after a prior authorization policy change (analyzed using a quasi-experimental difference-in-differences event study). RESULTS The introduction of a new prior authorization on an established drug increased the odds of discontinuation within 120 days (adjusted odds ratio, 7.1 [95% CI, 6.0 to 8.5]; P < .001) and increased time to next fill by 9.7 days (95% CI, 8.2 to 11.2; P < .001), relative to patients whose plans did not have a prior authorization policy change. CONCLUSION Introduction of a new prior authorization policy on an established drug regimen is associated with increased probability of discontinued and delayed care. For some conditions, this may represent a clinically consequential barrier to access. Waiving prior authorization for patients already established on a drug may improve adherence.

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage

“…41 The considerable scope of services requiring PA may lead to reductions in the provision of low value services, but it can impose an administrative burden on the clinicians who must navigate these policies, and the insurer staff who adjudicate the claims. Patients may also face barriers or delays in obtaining appropriate care, 42 43 44 particularly if therapeutic substitutes are lacking. Because most PA requests are eventually approved, reforms may be particularly promising if they reduce administrative burdens for services most likely to be approved 45 ; to infer whether a PA request is likely to be approved, insurers might employ readily available data about a patient or clinician (eg, the patient’s previous diagnoses or the physicians’ rate of PA approvals).…”