Prescription drug denials from private payers grow 25% in 7 years: Report

Prescription denial rates from private insurers grew from 18.3% in 2016 to 22.9% in 2023 — a 25% increase, according to a July 18 article from The New York Times. 

Healthcare analytics company Komodo Health conducted an analysis of more than 4 billion claims; the data comes from pharmacies, payers and pharmacy benefit managers. 

Most private payers do not publish information on denial details, according to the report, making Komodo Health’s research a rare model for a concern patients and healthcare leaders have voiced for years: Insurance rejections are climbing. 

Experts told the Times the use of AI in processing claims and the high prices of GLP-1s for weight loss may be contributing to increased rejections. 

Among five major health plans, prescription denial rates increased 25% at Cigna, 24% at Aetna, 23% at UnitedHealthcare, 22% at Anthem and 20% at Humana between 2016 and 2023, according to Komodo. These increases are higher than public insurance and employer-funded insurance plans during the same time period. 

The research does not cover what happens after prescription claims are denied, but insurance industry officials said replacement claims for the same medication are usually approved. 

UnitedHealthcare, Aetna, Humana and Anthem declined to comment on the data, and Cigna did not respond to the Times‘ requests for comment. In a statement, a UnitedHealthcare spokesperson said most rejected claims that are followed by a subsequent claim for the same drug are approved by the company.