Specialty Drug Coverage Varies Across Commercial Health Plans In The US

We analyzed 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 Food and Drug Administration (FDA). Across 3,417 decisions, 16 percent of the 302 drug-indication pa...

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Bibliographic Details
Published in:Health Affairs Vol. 37; no. 7; pp. 1041 - 1047
Main Authors: Chambers, James D., Kim, David D., Pope, Elle F., Graff, Jennifer S., Wilkinson, Colby L., Neumann, Peter J.
Format: Journal Article
Language:English
Published: United States The People to People Health Foundation, Inc., Project HOPE 01.07.2018
Subjects:
Access
Cancer
Cancer therapies
Clinical trials
Combination therapy
Costs
Decision analysis
Decision making
Decisions
Disease
Drug Prescriptions - economics
Drugs
FDA approval
Food
Health
Health Benefit Plans, Employee - statistics & numerical data
Health care expenditures
Health care policy
Health Expenditures - statistics & numerical data
Health Expenditures - trends
Health insurance
Health services
Healthy food
Humans
Insurance Coverage - statistics & numerical data
Medicare
Orphan Drug Production - economics
Orphan Drug Production - statistics & numerical data
Patients
Pediatrics
Pharmaceutical industry
Regression analysis
Regulatory agencies
Safety
Sensitivity analysis
Warnings
United States > US
Insurance Coverage < Insurance
Pharmaceuticals
ISSN:0278-2715, 2694-233X, 1544-5208, 2694-233X
Online Access:Get full text
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Summary:We analyzed 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 Food and Drug Administration (FDA). Across 3,417 decisions, 16 percent of the 302 drug-indication pairs were covered the same way by all of the health plans, and 48 percent were covered the same way by 75 percent of the plans. Specifically, 52 percent of the decisions were consistent with the FDA label, 9 percent less restrictive, 2 percent mixed (less restrictive in some ways but more restrictive in others), and 33 percent more restrictive, while 5 percent 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 pediatric 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.
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ISSN:0278-2715
2694-233X
1544-5208
2694-233X
DOI:10.1377/hlthaff.2017.1553