Even with good insurance, many Americans face a second, quieter battle: getting their prescribed medications without delay or financial distress. Between sky-high drug prices, complex benefit designs, and prior authorization hurdles, coverage alone doesn’t guarantee access.
Why Drug Prices Keep Climbing
The United States spends far more on prescription drugs than other developed nations. As KFF reports, Americans spent about $1,126 per person on prescription drugs in 2019—nearly double the per-capita spending of comparable countries.
That’s largely due to how our system sets and protects drug prices: manufacturers can launch new medications at virtually any price, shielded by patent exclusivity and limited competition. KFF Health News notes that specialty and biologic drugs—though a small fraction of prescriptions—account for more than half of all spending.
💬 “High launch prices and limited negotiation power make the U.S. an outlier in global drug spending.” — KFF, 2024
Prior Authorization: A Safety Valve or a Wall?
To control drug costs, insurers use prior authorization (PA) and step therapy—rules requiring proof of medical necessity before covering a prescription.
On paper, PA promotes safe, evidence-based care. In practice, it often delays or denies access.
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The American Medical Association found physicians complete 43 prior authorizations per week, spending 12 hours weekly on PA tasks.
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Over 90% report that PA causes care delays, and 78% say it leads some patients to abandon treatment.
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AMA research also links PA delays to higher overall costs through hospitalizations and emergency visits.
The American College of Physicians estimates that these administrative tasks cost primary care practices $2,000–$3,400 per year per physician. (ACP Toolkit)
When Approval Isn’t the End of the Story
Even after authorization, many patients face staggering out-of-pocket costs. Co-pays and coinsurance for specialty drugs can easily exceed $1,000 per month.
Common barriers include:
✅ High cost-sharing: Plans often cover only a portion of expensive medications.
✅ Short-term assistance programs: Manufacturer co-pay programs may expire or fail to count toward deductibles.
✅ Annual reauthorization: Patients stable on therapy can suddenly lose access if paperwork lags.
The result: treatment delays, medication rationing, and poorer outcomes—all while total system costs rise.
Signs of Progress
Despite the frustration, policy momentum is building.
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Medicare negotiation: The Inflation Reduction Act now allows the government to negotiate prices for select high-cost drugs and cap price increases at inflation.
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PBM transparency laws: More states are regulating “spread pricing” and requiring transparency in rebate flows. Health System Tracker reports that 16 states now restrict PBM spread pricing.
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Streamlining prior authorization: The AMA, ACP, and others advocate for automated, real-time PA systems and exemptions for chronic medications.
Value-based contracts—tying price to patient outcomes—are also gaining attention as a way to link cost and clinical benefit.
Why It Matters for Brokers and Employers
For the benefits industry, this isn’t just a patient issue—it’s a business one:
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Premium Pressure: Poor adherence and delayed care increase downstream costs.
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Employee Frustration: Members who hit administrative walls lose faith in their benefits.
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Plan Design Challenges: Employers need smarter tiering, carve-outs, and support tools.
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Compliance Risks: Rapidly changing state and federal rules on drug pricing and utilization management mean plan sponsors must stay nimble.
💬 “Coverage doesn’t always equal care. Understanding the system’s friction points is the first step to improving value.” — Benefits Weekly Editorial Board
Bottom Line
For brokers and benefits leaders, the takeaway is clear:
Drug affordability and access are converging policy, HR, and compliance issues.
Knowing how prior authorization, PBM practices, and new laws intersect will be essential to protecting clients and improving employee health outcomes in 2026 and beyond.