Insurance Hurdles Delay Care and Force Tough Choices
Key takeaways:
According to new data from GoodRx Research, about 1 in 5 people taking prescription medications in the past year have encountered restrictions on their insurance coverage, like prior authorization.
Consumers report that undergoing the process of additional insurance requirements is time-consuming and difficult to the point that 57% said they were considering changing their insurance plan.
Over 30% of people facing insurance restrictions declined to go through the process, opting instead to fill a different medication, pay cash, or skip their fill altogether.
For millions of Americans — even with insurance, getting a prescription filled isn’t as simple as heading to the pharmacy. New data reveals that nearly 1 in 5 patients (19%) encountered insurance restrictions in the past year, forcing them to either pay fully out of pocket, find an alternative medication, or take extra steps to get coverage. These hurdles, often in the form of prior authorization or step therapy, leave patients frustrated, delaying care and sometimes resulting in people abandoning their prescribed treatment altogether.
Delays, denials, and difficult decisions
GoodRx Research surveyed 3,000 people with a prescription, and found that 1 in 3 (34%) lacked unrestricted insurance coverage for their medication. Without coverage, out-of-pocket costs for medications can be much higher.
Over half of those people knew they could get coverage for their prescription if they took additional steps like prior authorization or step therapy. That means that about 1 in 5 people (19%) faced restrictions on their insurance coverage for a medication they were prescribed.
For those who knew that additional steps could have made their medication eligible for coverage, 69% went through the often tedious process, while 31% opted out. As a result, only 13% of people with a prescription actually go through the restrictions process.
A process riddled with frustrations
Of those who did go through the extra steps, 75% had to complete prior authorization, requiring their doctor to submit additional paperwork proving the necessity of the medication. Nearly 30% had to go through step therapy, meaning they were forced to first try a different, often cheaper, medication before their insurance would approve their prescription.
Even for those who succeeded, the process wasn’t always quick: 30% waited longer than 2 weeks, with 11% enduring delays of over a month. Nearly 21% found the process difficult or very difficult, adding stress to an already frustrating experience.
Patients rethink their insurance coverage
These barriers are having ripple effects beyond the pharmacy counter. Over half of patients (56) said the extra steps made them consider stopping their medication altogether. Similarly, 57% said the hassle made them think about switching insurance plans next year.
This is a notable finding, given that researching and selecting an insurance plan can be a time-intensive process. And prioritizing an insurance plan based on its drug formulary can mean trade-offs for other types of benefits. Plus, health plans don’t just update their formularies yearly, but also make changes throughout the year. While there's a clear desire for more streamlined and comprehensive coverage, the path to it is anything but easy.
But what happens when people decide not to navigate these barriers? Over 40% simply didn’t fill their prescription at all, while 34% report switching medications. This could include asking their prescriber to recommend a different, covered medication, or switching to an over-the-counter alternative. Nearly 1 in 4 people (23%) who skipped the restrictions process decided to just pay cash instead of going through insurance.
Even those who managed to get an alternative medication weren’t always satisfied. With just 20% of people reporting that they were very satisfied with an alternative medication, and another 10% reporting dissatisfaction, insurance-imposed suggestions are clearly not an ideal solution.
How much would people pay to avoid the hassle?
Many people would prefer to sidestep the restrictions altogether. Two-thirds (67.9%) said they would be willing to pay something out of pocket to bypass the process, with 15.3% saying they’d pay more than $100.
The insurance restrictions process can be costly for both patients and healthcare offices. For example, studies estimate that every prior authorization request “costs” about $15 extra in staff time. Put together with the time cost to consumers, insurance restrictions may actually be much more expensive than they appear.
A system that leaves patients struggling
For some, the prior authorization and step therapy process is more than just an inconvenience — it’s a roadblock to necessary care. Patients reported battling insurance companies, coordinating with doctors, and spending weeks waiting, all while their health hung in the balance. “It makes no sense — if the doctor orders it, it should go through,” one respondent vented. Another shared, “I had to wait several months for the approval to go through.”
The data paints a clear picture: Insurance restrictions are causing delays, extra costs, and, in some cases, real harm. While insurance companies often justify these policies as cost-control measures, they frequently shift the burden onto patients. This leaves patients with tough choices, unnecessary stress, and an uphill battle just to access the medications they need.
Methodology
Our survey was run through YouGov from November 8, 2024 to January 21, 2025. Our sample population was adults who were prescribed a medication in the prior month; 3,000 responses were collected and analyzed. Survey responses were weighted to the U.S. population using age, gender, race, political affiliation, and education level. The YouGov survey research arm provides more information.
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