Posted by Michael Wonder on 10 Jul 2018
Specialty drug coverage varies across commercial health plans in the US
9 July 2018 - Chambers et al. analysed specialty drug coverage decisions issued by the largest US commercial health plans to examine variation in coverage and the consistency of those decisions with indications approved by the FDA.
Across 3,417 decisions, 16% of the 302 drug-indication pairs were covered the same way by all of the health plans, and 48% were covered the same way by 75% of the plans. Specifically, 52% of the decisions were consistent with the FDA label, 9% less restrictive, 2% mixed (less restrictive in some ways but more restrictive in others), and 33% more restrictive, while 5% of the pairs were not covered. Health plans restricted coverage of drugs indicated for cancer less often than they did coverage of drugs indicated for other diseases.
Using multivariate regression, we found that several drug-related factors were associated with less restrictive coverage, including indications for orphan diseases or paediatric populations, absence of safety warnings, time on the market, lack of alternatives, and expedited FDA review. Variations in coverage have implications for patients’ access to treatment and health system costs.
