Prior authorization, the process by which doctors must obtain approval from health insurance companies before certain treatments are applied, may prevent patients from filling prescriptions for two important heart failure drugs, a new study shows.
The analysis, led by researchers at NYU Langone Health, focused on angiotensin receptor neprilysin inhibitors (ARNIs) and sodium-glucose cotransporter 2 (SGLT2) inhibitors, the mainstays of modern heart failure treatment. These drugs have no generic alternatives and can cost hundreds of dollars out-of-pocket. Adding these drugs to standard care has been shown to significantly reduce the risk of death, but past studies have shown that less than half of patients prescribed these drugs take them regularly.
Heart failure patients whose prescriptions required prior authorization took three times longer to fill a prescription for ARNI and six times longer to fill a prescription for an SGLT2 inhibitor than patients whose prescriptions did not require prior authorization, according to the results of a new study. Patients who received an SGLT2 prescription that required prior authorization were twice as likely to never fill the prescription.
Our results suggest that prior authorization may be harmful for guideline-recommended drugs for which there are no generic alternatives. Although these policies are intended to control health care costs by directing patients to lower-cost alternative treatments, they may instead prevent heart failure patients from accessing life-saving treatments in a timely manner. ”
Dr. Amrita Mukhopadhyay, lead study author, cardiologist
Mukhopadhyay is Eugene Braunwald, MD, assistant professor of cardiology in the New York University Grossman School of Medicine and the Leon H. Charney Division of Cardiology.
According to the authors, most patients fill their prescriptions on the day of their visit, which can lead to late or missed prescriptions. Some people may give up on treatment if the pharmacy asks them to come back in a few weeks. Mukhopadhyay, who is also an assistant professor in the Department of Population Health at New York University’s Grossman School of Medicine, added that clinicians may also be hesitant to prescribe the drug if they know it requires prior approval.
The findings are consistent with interviews and surveys of doctors and patients that have long suggested that prior authorization requirements can delay treatment, increase abandonment and undermine trust in the health care system, Mukhopadhyay said.
Published in an online journal on January 27th JACC: ProgressThe study is the first to examine the impact of prior authorization on access to ARNI and SGLT2 inhibitors prescribed for heart failure, and provided clear evidence that it can significantly delay pharmacy refills, the researchers said.
For their study, the researchers evaluated information from the electronic health records and pharmacy records of 2,183 men and women treated for heart failure at NYU Langone Health. All received a new prescription for an ARNI or SGLT2 inhibitor between 2021 and 2023.
For each patient, the team determined whether prior authorization was required and how long it would take to fill a prescription within a year of writing it. Researchers considered patients’ race, ethnicity, gender, education, and other demographic and social factors in their statistical analysis.
They found that prior permission was more common among people who lived in areas of lower socio-economic status and who identified as black or Hispanic. Patients facing these prior authorization requirements were also more likely to have Medicaid insurance. The researchers say this suggests that these policies may be contributing to health disparities.
“Our results indicate that prior authorization requirements may be contributing to the significant health disparities seen in heart failure treatment and should be carefully reconsidered,” said Saul Brecker, MD, PhD, lead author of the study.
Brecker, an associate professor in the Department of Population Health Medicine at New York University’s Grossman School of Medicine, said the research team will next examine how co-pays, coinsurance and other insurance factors affect access to heart failure drugs.
Professor Brecker cautioned that because the study evaluated patients within a single health system, the findings may not be easily generalizable to the whole country. Because New York State’s Medicaid offers the most comprehensive coverage policy in the nation, other states may have higher barriers related to prior authorization.
The National Institutes of Health awarded grants R01HL155149, R01HL152699, K23HL171636, and K24AG080025, and the American Heart Association and New York Academy of Medicine funded this research.
In addition to Mukhopadhyay and Blecker, NYU Langone researchers and other NYU researchers involved in the study are Dr. Samrachana Adhikari; Xuyue Li, MS; Adam Berman, MD, MPH. Karine Hamo, MD. John Dodson, MD, MPH. Dr. Rumi Chunara, M.S. Natalia Ladino, Mississippi; Harmony Reynolds, MD. and Dr. Stuart Katz.
Other study collaborators are Dhruv Satish Kazi, MD, PhD, of Harvard Medical School in Boston, and Ian Kronisch, MD, MPH, of Columbia University in New York City.
Reynolds has received funding for unrelated research from biotech companies Abbott, Philips, and Siemens. NYU Langone Health governs the terms and conditions of these relationships in accordance with its policies and procedures.
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Reference magazines:
Mukhopadhyay, A. Others. (2026). Prior authorization requirements and prescription filling patterns for heart failure patients. Jack: Progress. DOI: 10.1016/j.jacadv.2025.102583. https://www.jacc.org/doi/full/10.1016/j.jacadv.2025.102583
