16% of specialty drugs are covered the same way by commercial health plans

Commercial health plans vary widely in how they cover specialty drugs, and coverage is not typically based on available evidence-based data, according to a study from Tufts Medical Center researchers published online July 9 in Health Affairs. 

The variation impacts both physicians and patients in terms of care delivery.

“Inconsistencies among health plan decisions suggest that a person’s plan can greatly influence their access to particular specialty drugs,” wrote James D. Chambers, PhD, MPharm, MSc, and colleagues. “Moreover, our study suggests that in their prescribing decisions, physicians must consider not just a patient’s clinical presentation but also their insurance coverage.”

Health plans, in deciding how drugs are covered for enrollees, base these decisions on several factors once drugs are approved by the FDA. But health plans are inconsistent and typically use different algorithms.

Only 16% of drug-indication pairs analyzed in Tufts Medical Center’s Specialty Drug Evidence and Coverage Database had the same coverage across the health plans that reported data. Nearly halfof pairs—48 percent—were covered the same by at least 75 percent of the health plans.

More than one-third of plans covered specialty drugs in a more restrictive way than recommended by the FDA or didn’t cover them at all.

The study examined 158 drugs for which the included health plans more often issued coverage decisions. Researchers stated that, ideally, specialty drug coverage decisions should be evidence-based, transparent and publicly available. They noted it is unclear why the discrepancies currently exist.

Still, there are some possible explanations for the inconsistencies, as plans may tailor decisions to their specific patient populations. Health plans negotiate different discounts with product manufacturers or contract differently, and they can be influenced by budgetary pressures and varying available financial resources. Some plans consider other factors, such as cost-effectiveness analyses, while others do not, according to the study.

In more than half of cases, health plans’ coverage was found to be consistent with FDA indication. Health plans were less likely to restrict drug coverage for certain diagnoses, including cancer, orphan diseases and pediatric populations, instead placing more restrictions on noncancer diagnoses and adult populations.

Self-administered drugs, as opposed to those administered by physicians, were found to have more coverage restrictions, along with those more recently approved by the FDA. Low-cost drugs were associated with fewer restrictions, and overall restrictions were not closely correlated with evidence.

“Moreover, sensitivity analyses suggested that drugs with higher annual costs and greater budget impacts were more likely to be covered restrictively than drugs with lower annual costs and smaller budget impacts,” Chambers et al. wrote. “We did not find a strong association between restricted coverage and the evidence payers cited in their coverage decisions.”