Insurance Coverage Doesn't Guarantee Medication Access, SHARx Says

Prior authorizations, formulary exclusions, step therapy, and specialty pharmacy restrictions can delay treatment even when medications are technically covered, SHARx says.

ST. LOUIS, July 14, 2026 /PRNewswire/ -- Patients often are told a medication is covered and assume access will follow. But SHARx shows administrative barriers, including prior authorization requirements, step therapy protocols, formulary exclusions, and specialty pharmacy restrictions, are increasingly determining whether people can actually begin or continue treatment.

For employers, those delays can create more than frustration. When treatment is disrupted, symptoms can worsen, time is lost to repeated calls and appeals, and benefit plans meant to support employees can become another source of instability for workers and their families.

"Too often, covered does not mean accessible," said Paul Pruitt, Chief Growth Officer of SHARx. "Patients and families are told the medication is covered on the plan, but that does not mean they can get it without a maze of administrative hurdles. People need to be able to access the treatment they need."

Specialty Drugs Face the Greatest Access Barriers

SHARx says the burden is most prevalent in specialty medications, where scrutiny and approval friction are most common. Branded drugs and generics can also face delays, but specialty medications, particularly in complex categories such as oncology and autoimmune care, are more likely to trigger repeated reviews, access restrictions, and time-consuming approval processes.

For one SHARx member, that gap between coverage and access became both a medical and financial crisis. After the member's condition failed to respond to first-and second-line therapies, the health plan refused to cover a third-line treatment that would have cost about $10,000 per month out of pocket, an impossible burden for a medical student already carrying significant debt. Without the medication, the member faced the risk of life-threatening complications.

"SHARx has been a literal lifesaver by providing my medication at no cost to me," the member said. "I hope SHARx is still around when I become a doctor!"

Other members describe a different version of the same problem: not only whether a prescription is covered, but how much time, effort, and uncertainty stand between a patient and the medication they need.

"I´ve made monthly trips to pharmacies chasing down my meds because of availability. It's outstanding that through mail order, I can just have a 3-month supply shipped directly to my house," another SHARx member said.

A third member summed it up simply: "SHARx got a prescription filled for me when my regular insurance would not. I recommend them to anybody who needs help."

SHARx works with members to navigate approval obstacles, identify alternative access pathways, and reduce the administrative steps that can delay physician-prescribed care. The company says these barriers are not isolated paperwork issues. They can affect whether employees remain functional, mobile, and able to work while managing chronic or serious conditions.

National Data Show Access Barriers Are Widespread

The access barriers SHARx describes reflect a much broader national problem. In a 2025 KFF poll, 51% of insured adults said they, or their provider, had to seek prior authorization in the past two years, and nearly half said the process was difficult to manage. The same poll found that 73% of adults consider insurer delays and denials a major problem.

Physicians are reporting the same pattern from the clinical side. TIME, citing a 2024 American Medical Association survey, reported that 93% of physicians said prior authorization delayed necessary care, 82% said it can lead patients to abandon treatment, and more than one in four said it had caused a serious adverse event for a patient.

Even as insurers have pledged new reforms, public confidence remains low. KFF found that 60% of adults do not believe health insurers are likely to follow through on those promises in a way that materially improves care for patients.

Delays Carry Consequences Beyond the Claim

SHARx says employers and benefits leaders should pay closer attention not only to what medications cost on paper, but also to how difficult the system makes it for employees to receive them. In the company's view, a health benefit cannot be judged by coverage language alone if workers still face repeated delays, rerouting, and approval hurdles when trying to access physician-prescribed treatment.

"Administrative friction has become its own form of access denial," Pruitt said. "Families can spend hours trying to figure out why a medication was delayed, where it can be filled, or what additional approval is required. If an employee still has to fight the system to get the treatment their doctor prescribed, the benefit is not working the way it was intended."

About SHARx
SHARx was founded to fight back against the broken system of overpriced prescription drugs. Industry pioneers Corey Durbin and Paul Pruitt built SHARx to put people before profits. With an innovative and ethical sourcing model, SHARx cuts through the waste with radical transparency, common-sense cost containment, and a member-first approach. No hidden markups. No games. Just the meds people need, delivered affordably, reliably, and with dignity. Learn more at  SHARXplan.com.  

Sources:

• TIME. "Health Insurers Vow—Again—to Fix Prior Authorization Process. Here's What to Know" (2025) time.com/7297420/health-insurance-prior-authorization/
• KFF Health News. "5 Takeaways from Health Insurers' New Pledge to Improve Prior Authorization" (2025) kffhealthnews.org/health-industry/5-takeaways-from-insurers-pledge-to-improve-prior-authorization/
• KFF. "KFF Health Tracking Poll: Public Finds Prior Authorization Process Difficult to Manage" (2025) kff.org/patient-consumer-protections/kff-health-tracking-poll-public-finds-prior-authorization-process-difficult-to-manage/

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SOURCE SHARx