Insurance Access Barriers Impede Patient Drug Therapy
Healthcare operators must navigate stricter step-therapy and copay rules that significantly delay patient treatment access.
Updated on Oct. 22, 2026 in Healthcare
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Patient advocates at the BIO Patient Advocacy Changemakers Event highlighted how utilization management and copay policies frequently block access to essential treatments. These insurance practices significantly impact pharmaceutical access for patients with chronic conditions.
Why it matters
Operators in the healthcare sector must navigate shifting insurance coverage requirements that can delay treatment and change how patients utilize assistance programs. These barriers increasingly disconnect patient access from modern biopharmaceutical innovations.
Insurers and pharmacy benefit managers now redirect $7 billion of the $20 billion in annual patient copay assistance through accumulator and maximizer policies. Additionally, 90 percent of Medicare patients report experiencing utilization management, compared to 80 percent of psoriasis patients.
The players
BIO
The trade association representing biotechnology companies, academic institutions, and related organizations involved in biopharmaceutical innovation.
HIV+Hepatitis Policy Institute
A research and policy organization that advocates for improved access to care and treatment for individuals living with HIV and hepatitis.
National Psoriasis Foundation
A non-profit advocacy group that provides support and pushes for improved health access for people with psoriasis and psoriatic arthritis.
The details
Insurers utilize step therapy and prior authorization as gatekeeping mechanisms to control pharmaceutical access. For instance, one insurer previously required psoriasis patients to attempt 14 therapies over 42 months before approving a specific drug, though advocacy reduced this to 5 therapies and 15 months. PBMs further impact these economics by applying accumulator and maximizer policies to capture copay assistance funds that would otherwise lower out-of-pocket patient costs.
Timeline
Three years ago, the HIV+Hepatitis Policy Institute filed a discrimination lawsuit against insurers.
Earlier in 2026, a health insurer released a policy requiring patients to try 14 therapies over 42 months for a psoriasis treatment.
October 22, 2026, marked the BIO Patient Advocacy Changemakers Event in Washington, DC.
Market Landscape
The ongoing struggle of advocates to enforce coverage standards highlights a broader tension between clinical innovation and the restrictive policies often used by insurers. This mirrors historical challenges in enforcing the Affordable Care Act's essential health benefits requirements.
Operators in the pharmacy and provider spaces should track how utilization management protocols are trending toward longer step-therapy requirements. Managing these insurance hurdles now necessitates active advocacy to ensure patients can access approved therapies without excessive waiting periods.
The takeaway
Access to patient-requested therapies frequently stalls due to aggressive insurer gatekeeping, necessitating that providers anticipate longer wait times and multiple alternative trials for patients. Organizations should monitor their regional insurer's step-therapy requirements as a key metric for treatment access.
Further reading
For more on evolving standards in clinical care, read the latest coverage in Healthcare.
Source note: This article includes information reported by Bio.
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