Prescription Medication Access Challenges
On a warm summer day, fresh from the high of the World Cup final, I was in clinic chatting about soccer with a patient when they shared that a diabetes medication prescribed last visit was not covered by insurance, so their home glucose readings were elevated. “Not again,” I thought. A list of possible barriers came to mind, so I spent a few minutes figuring out whether there was an issue with the initial prescription, whether the prior authorization was completed, if insurance changed since the last visit, or if the patient requested the refill too soon. It turned out that the prior authorization was not completed, so I added “complete PA for patient” to my to-do list.
In my practice, it is fairly common to see prescription coverage barriers affecting patients’ chronic illness control. These regular occurrences cause frustration and require providers to spend additional time outside direct patient care to ensure patients get the medications they need.
Navigating prescription coverage through insurance is challenging. Since medication access is tied to insurance, I am concerned about upcoming health policy changes impacting coverage, such as increases in premiums for Covered California and new eligibility requirements for some Medi-Cal patients. Our patients with unsatisfactory immigration status have also been excluded from Medi-Cal eligibility. Additionally, H.R. 1 narrows federally funded Medicaid eligibility for various categories of lawfully present immigrants beginning October 1, 2026.
Fortunately, California has temporarily allocated state funding to preserve coverage for some people losing federal eligibility under H.R. 1. Under 2026 budget policy, many of these adults will transition to emergency Medi-Cal beginning July 1, 2027. This serves as a helpful bridge, but it is not a permanent expansion of eligibility and will ultimately leave patients with more limited access.
There are also some small wins to help patients get their medications: SB 306 was recently enacted, which requires insurers to report prior authorization approval data. Services approved at least 90% of the time may eventually be exempted from prior authorization, with the first exemptions beginning in 2028. Unfortunately, this law does not apply to Medi-Cal managed care plans. SB 40 caps insulin cost sharing at $35 per 30-day supply for large-group plans in 2026, and for individual and small-group plans in 2027.
With both progress and significant challenges ahead, both patients and physicians need to be equipped with tools to help improve medication access. So, what can we do?
First, patients can be informed about potential discount and assistance programs. If eligible, patients may benefit from manufacturer coupons or copay cards, prescription discount programs such as GoodRx, lower-cost online pharmacies such as Cost Plus Drugs, and manufacturer patient assistance programs. Patients can also be referred to 211 LA, which can connect them with prescription assistance programs. Patients should also be aware that some discounts, such as through GoodRx, cannot be combined with insurance or any federal or state-funded program.
Medi-Cal Rx provides pharmacy benefits for Medi-Cal patients. Many community health centers participate in the federal 340B Drug Pricing Program, which allows eligible organizations to purchase outpatient medications at discounted prices.
Physicians should become familiar with their health system’s workflow, electronic health record, and formularies. It is helpful to identify alternatives to medications that regularly trigger prior authorizations or denials. Common examples include prescribing lidocaine patches for pain unrelated to postherpetic neuralgia, or prescribing an asthma inhaler that is not on the patient’s preferred formulary. Familiarity with commonly covered alternatives can reduce delays in treatment and decrease the administrative burden for both patients and providers.
For Medi-Cal patients, ensure that prescriptions are initially billed through Medi-Cal Rx. I recommend bookmarking the Medi-Cal Rx Preferred Drug List so clinicians can quickly identify covered medications and preferred alternatives.
Physicians can also prescribe generic medications whenever possible, remind patients about discount cards, and recommend less expensive over-the-counter alternatives when appropriate.
A more system-wide approach to improving medication prescribing practices includes compiling a list of common prescription issues that prompt rejections or prior authorization requests, such as an incorrect quantity, strength, or frequency, and discussing these patterns with your clinic’s informatics team to improve electronic health record prescribing defaults.
The AAFP FPM Journal article, “Reducing the Burden of Medication Prior Authorizations” provides additional practical recommendations.
Continued advocacy for prescription access reform is essential to further improve prescribing practices and patient access to care. These efforts can help prevent delays like the one experienced by my patient, and allow physicians to focus more time on patient care. For those interested in legislative proposals and advocacy efforts, I recommend getting involved with the LAAFP and the CAFP.
