Economic Impact of Anti-Vascular Endothelial Growth Factor Prior Authorization Process From a Large Electronic...

Purpose:To determine the economic impact of insurance company prior authorizations (PAs) for anti-vascular endothelial growth factor (anti-VEGF) therapies on society. Methods: PA denial and delay rates were derived from a large electronic database (SamaCare PA). Data were analyzed in a theoretical cost-effectiveness model to calculate the increased costs of PAs (in 2025 U.S. dollars). Results: Of 33 178 total PA requests, the majority were from Medicare Advantage plans (18 769, 58.2%), followed by commercial insurance carriers (10 047, 31.1%) and Medicaid (3438, 10.7%). Commercial carriers had the highest mean PA denial rates and approval delays (3.95% denials, 4.95 days delayed), followed by Medicaid (3.87% denials, 4.11 days delayed) and Medicare Advantage (1.18% denials, 1.54 days delayed). Over the average patient's lifetime, the PA process increased total societal costs by a mean $10,842.24 (range, $228.11-$90, 322.69), and the direct savings from denying a PA was only $27.11 per injection (range, $3.06-49.99). Each PA request increased the mean total societal costs by an additional $637.78 in the reference case (range, $25.35-$4,105.58). PAs annually cost the workplace an extra $588.17 (range, $9.98-$3,513.90), the patient and family an extra $362.92 (range, $20.93-$1,743.63), the provider an extra $11.61 (range, $1.14-$324.18), and the insurer an extra $4.92 per year (range, -$40.85 to $76.03). PAs were not cost saving in >99.9% of modeled scenarios. Insurance companies were the only sector of society to potentially save money. Conclusions: PA requests were ultimately approved in 97.7% of all cases, with 97.9% being delayed. The PA process was not cost-saving and increased the total societal costs of anti-VEGF treatments.