Treatment Delays, Denials More Common in Prescriptions Initially Rejected

Treatment delays or eventual denials were experienced by most patients who filled out their prescripts that prior authorization (PA) had initially rejected, according to a new study published in JAMA Health Forum.¹

Health insurance plans can approve or deny the delivery of some covered health services or medications through the process of PA, which was initially designed to contain health spending and reduce unnecessary care.² However, it is possible that PA can lead to patients being unable to access the care that they need, including through delays in PA or denials of needed treatment. This study aimed to identify the PA process at the drug prescription event and assessed the level and variation in processing time for PAs. Final outcomes for medications that initially encountered PA rejections were also assessed.

The researchers used the 2024 IQVIA Formulary Impact Analyzer outpatient pharmacy claims database for this study, which gives data on retail pharmacies. Rejection reasons are also included as part of the approximately 58% of national retail pharmacy transactions included in the database. The researchers focused on brand medications that did not have a generic equivalent. Prescription fill transactions (PFT) for each patient, prescribing clinician, number of dispensing events, prescription written date, and drug molecule were identified. PFTs were excluded if there were multiple plans within a transaction.

There were 205,896 finalized PFTs included in this study that were initially faced with a PA rejection, made up of 731,237 individual claim lines from 156,848 patients, 104,501 clinicians, and 88 drug molecules.

A total of 54% of the PFTs were ultimately approved, of which 7% were approved on the same day and 47% were approved after multiple days. A total of 27% of the rejected claims were done within 1 day, and 19% were rejected after multiple days. Ubrogepant (40%) was the most common medicine to be approved on the same day, and evolocumab was the least common (29%). Evolucumab did have the highest approval rate (66%), and tirzepatide had the lowest (49%).

PFTs that had multiple rounds of PA review were less likely to be processed on the same day and PFTs with additional rejection reasons were also less likely to be processed in 1 day but had a higher chance of being approved. Refills also had higher approval rates compared with first fills, but medications with more than a 30-day supply were less likely to be approved.

Same-day approvals were highest in patients with Medicaid (38%) compared with Medicare (34%) or commercial insurance (32%). However, Medicaid had the lowest approval rates compared with the other types of insurance (48% vs 60% and 56%, respectively). Lower approval rates were also found in women compared with men (53% vs 56%). Patients with only 1 condition had higher approval rates compared with those with multiple disease conditions (57% vs 51%).

PFTs that had multiple rounds of PA review had a lower probability of a same-day decision (37%; 95% CI, 37%-37%). PFTs that had additional rejection reasons and refills had a 17% and 19% higher probability of being approved, respectively, despite having a lower probability of a same-day decision. A slightly higher chance of a same-day decision was found in patients with Medicaid and commercial insurance compared with those on Medicare, but they had lower approval rates.

There were some limitations to this study. Measurement inaccuracies are possible due to the use of administrative data. All of the included drugs were branded drugs. The study was cross-sectional, and causal relationships could not be confirmed. Patient behavior after a PA denial was not collected. Prescriptions that were immediately approved were not observed. The effect of PA requirements on prescribing behavior was not analyzed. The clinical appropriateness of the prescription was also not assessed.

“This cross-sectional study using national pharmacy claims data with adjudication details found that most branded drug prescriptions that were initially rejected by PA were delayed for multiple days and/or denied,” the authors concluded. “Our findings inform patients and clinicians regarding the dynamics and nuances of the PA process and support payers in improving the PA process to balance cost containment with timely access to treatment.”

References

1. Wang Y, Levy JF, Mattingly J, Anderson G. Prior authorization and associated delays and denials of branded medication dispensation. JAMA Health Forum. 2026;7(4):e260760. doi:10.1001/jamahealthforum.2026.0760
2. Levine H. Prior authorization: what is it, when might you need it, and how do you get it? Harvard Health Publishing. August 5, 2024. Accessed April 15, 2026. https://www.health.harvard.edu/healthy-aging-and-longevity/prior-authorization-what-is-it-when-might-you-need-it-and-how-do-you-get-it