Insurance rejections for brand-name prescription drugs with no generic competitors rose by 67% between 2018 and 2024, according to a study published in JAMA. Researchers from the Johns Hopkins Bloomberg School of Public Health and the American Enterprise Institute found that nearly 41% of initial prescription attempts for these drugs are now denied, often due to utilization management rules like prior authorization.
The Growing Barrier to Medication Access
Data from more than 2 million prescription attempts shows a significant shift in how insurers manage high-cost medications. In 2018, 24.3% of initial attempts to fill brand-name prescriptions were rejected. By 2024, that figure climbed to 40.7%. The study, which utilized the IQVIA Formulary Impact Analyzer, highlights that these denials are not just administrative hurdles; they frequently result in patients failing to receive treatment altogether.
According to the findings, 48.4% of patients whose prescriptions were initially rejected did not receive the prescribed drug or a therapeutic alternative within 90 days. For those who did eventually secure their medication, the process caused an average delay of 12 days.
Did you know?
Brand-name drugs make up only about 10% of total prescriptions filled in the U.S., yet they account for 88% of total prescription drug spending, according to the Association for Accessible Medicines.
Utilization Management as a Primary Driver
The primary reason for the surge in denials is the increased use of utilization management tools. Approximately 32% of initial rejections were attributed to formulary exclusions—where a drug is not covered by a plan—or restrictive rules requiring patients to try other medications first or obtain prior authorization from their insurer.
Joseph Levy, PhD, an assistant professor at the Johns Hopkins Bloomberg School of Public Health and lead author of the study, notes that while these policies aim to control spending, they create “meaningful barriers to timely treatment.” Commercial insurance and Medicaid managed care plans saw the most aggressive adoption of these restrictive policies during the study period.
Disparities Across Insurance Markets
Rejection rates are not uniform across all insurance types. The JAMA study indicates that marketplace exchange plans and Medicaid managed care plans report the highest denial rates, with nearly half of all initial attempts rejected. Medicare plans, by comparison, report lower rejection rates.
The impact also varies by drug class. Incretin-based therapies for weight loss, including GLP-1 receptor agonists, faced an 85% initial rejection rate. In contrast, oral anticoagulants saw a rejection rate of only 6.7%.
If your prescription is denied at the pharmacy counter, ask your pharmacist if the rejection is due to a “prior authorization” requirement. If so, contact your physician immediately to ensure they have submitted the necessary clinical documentation to your insurer.
Future Trends: Simplifying the Prior Authorization Process
The research suggests that the future of drug access may depend on how insurers manage the trade-off between cost control and patient care. The authors point to potential reforms, such as standardizing prior authorization requirements to reduce administrative friction for clinicians and patients.
Improved real-time transparency is also a potential trend. If clinicians have access to a patient’s formulary requirements at the point of prescribing, they may be able to choose alternatives that avoid the pharmacy counter delay entirely. However, the study warns that moving away from strict utilization management could lead to higher drug costs, as these tools are currently used by insurers to negotiate lower prices and encourage the use of evidence-based therapies.
Frequently Asked Questions
- Why was my brand-name prescription rejected? Rejections are often due to formulary exclusions or utilization management rules, such as requirements for prior authorization or “step therapy,” where you must try a different, cheaper drug first.
- How long does a typical denial delay treatment? Among patients who eventually received their medication, the study found an average delay of 12 days following the initial rejection.
- Are all drug classes rejected at the same rate? No. The study found that rejection rates vary significantly by therapeutic class, ranging from as high as 85% for certain weight-loss drugs to 6.7% for anticoagulants.
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