Health plans differ greatly in their approach to specialty drug use

Not all health plans treat coverage for specialty medications equally – in fact, they’re all across the board, according to the report, “Specialty Drug Coverage Varies Across Commercial Health Plans In The US,” published in Health Affairs.

Indeed, only 15.9 percent of drug coverage policies are consistent across the largest U.S. commercial health plans, and 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.

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“We expected to see some differences in drug coverage across plans due to differences in budgets and covered beneficiary populations — what was not known was the extent to which these coverage restrictions occurred,” says James Chambers, a Tufts associate professor of medicine and the lead author of the study. “We found that even if a drug was covered, many treatments had multiple restrictions prior to patients being able to access these medications.”

Differences between health plans in their specialty medication coverage could particularly impact patients who switch between insurers or employers and their care is disrupted, says Jennifer Graff, the council’s vice president of comparative effectiveness research.

“It also requires that physicians tailor care not only to diverse patients, but also to the multiple insurance plans that provide health care coverage,” Graff says.

The study also found that health plans often impose restrictions on specialty medication coverage. The most common restrictions 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 about a fourth of the decisions.

However, health plans were less likely to restrict coverage for children, as well as for patients who had rare diseases or 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 study’s authors say their 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.