Restricted access to specialty drugs on the rise: What employers, advisors need to know
Employers, benefit advisors and brokers need to consider that these restrictions can hinder patient access to the treatments their clinicians prescribe and worsen their outcomes while increasing health care costs, says a new study.
Access to specialty drugs through commercial health plans decreased from 2017 to 2021, and less than half of plans were consistent with FDA drug label indications, a recent study found. The National Pharmaceutical Council conducted the study in partnership with the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center.
“Our study indicates that the use of these restrictions is on the rise,” said Rochelle R. Henderson, Ph.D., who led the study. “It is important for employers, benefit advisors and brokers to consider that these restrictions can hinder patient access to the treatments their clinicians prescribe and worsen their outcomes while increasing health system costs. Our study suggests that some payers might be doing the math and not appreciating the downsides of placing hurdles in front of patients.”
Health plans determine access to prescription drugs with coverage policies that aim to achieve safe, effective and cost-effective care while also recognizing budgetary limits. For specialty drugs — which typically are complex, high-cost medications — commercial health plans often impose criteria that restrict coverage beyond the FDA’s label indications.
Among the key findings of the study:
- Overall, the proportion of policies that were consistent with the FDA label declined from 57% in 2017 to 45% in 2021.
- The proportion of policies that were more restrictive than the FDA label increased from 39.5% to 52% during the same period for a relative increase of more than 30% during the five-year period.
- The proportion of policies excluding drug coverage remained roughly constant in the same span.
- Plans’ use of coverage restrictions for oncology drugs nearly doubled, increasing from 17.6% to 33.5%. Non-oncology drug restrictions increased from 53% to 63.5%.
Brokers, advisors and employers can apply the study results to design better benefit plans, Henderson said.
Related: Rising costs, greater utilization drive increase in 2022 specialty drug spend
“Research has shown the importance of first-dollar coverage and the impact it has on patients getting the medications they need,” she said. “It is important for employers to understand what they are getting when designing benefits. While employers have turned to PBMs and consultants for guidance, NPC research shows they want more transparency from their PBMs and consultants. Putting these barriers in place may be penny-wise and pound foolish. Employers should be mindful of designing benefits that reduce spending on low-value care, thereby creating the headroom needed for life-saving medications that patients need.”