Insurance coverage and reimbursement for specialty medications varies substantially, with a new study published in Health Affairs finding that only 15.9 percent of drug coverage policies are consistent across the largest U.S. commercial health plans.
Less than half, 48 percent, of all drug coverage decisions are consistent across the majority of health plans, according to the study by the National Pharmaceutical Council and the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center.
Beyond FDA approval, health plans generally determine whether new treatments will be covered, and what restrictions to implement. While the researchers expected to see some differences in drug coverage across plans -- differences in budgets and covered beneficiaries lead to this variation -- they found that even covered drugs had multiple restrictions prior to patients being able to access them.
The findings have implications for both patients and providers. For patients, there may be disruptions in care if they switch between insurers or employers. For physicians, it requires they tailor care not only to diverse patients, but many different insurance plans that provide varied coverage.
Although 52 percent of coverage decisions were consistent with the FDA-labeled indication, restrictions were common. The most common restriction types were step edits, when a prior treatment must be proven ineffective before the plan will cover the treatment (73 percent); limitations on the types of physicians who could prescribe the medication (31 percent); and restrictions to certain patient subgroups (16 percent). There were multiple coverage restrictions in 22.5 percent of decisions.
Plans were less likely to restrict coverage for treatments indicated for pediatric populations, rare diseases and cancer. There were also fewer restrictions for medicines administered by a physician, without therapeutic alternatives, approved under an FDA-expedited review program, without safety warnings, or approved less recently.
The findings point to the need for greater transparency in the evidence used to determine plan coverage decisions, given the wide variations in plan coverage and restrictions.
The results were generated through a systematic review of coverage decisions contained within the Tufts Medical Center Specialty Drug Evidence and Coverage Database, which includes the most common policies for specialty medications issued by 17 of the 20 largest commercial health plans.