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. 2023 Aug 4;1(2):qxad030.
doi: 10.1093/haschl/qxad030. eCollection 2023 Aug.

Commercial coverage of specialty drugs, 2017-2021

Julia A Rucker  1 , Molly T Beinfeld  1 , Nola B Jenkins  1 , Daniel E Enright  1 , Rochelle R Henderson  2 , James D Chambers  1
Affiliations

Commercial coverage of specialty drugs, 2017-2021

Julia A Rucker et al. Health Aff Sch. .

Abstract

Health plans guide their enrollees' access to specialty drugs through coverage policies. We examined a set of health plan policies to determine if they have become more or less stringent over time. We did so by comparing the consistency of policies with Food and Drug Administration (FDA) label indications. We considered coverage policies for the same 187 specialty drugs issued by 17 large US commercial health plans from 2017 through 2021. Overall, the proportion of policies that were consistent with the FDA label declined from 57.1% in 2017 to 45.1% in 2021; the proportion of policies that were more restrictive than the FDA label increased from 39.5% to 51.7%. The proportion of policies excluding drug coverage remained approximately constant (3.4% in 2017; 3.2% in 2021). Trends in coverage restrictiveness varied across plans. For 13 plans, the proportion of policies with restrictions increased over time, while for 4 plans it declined.

Keywords: insurance coverage; pharmaceuticals; specialty drugs.

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Conflict of interest statement

Conflicts of interest This study was funded by the National Pharmaceutical Council. The Center for the Evaluation of Value and Risk in Health at Tufts Medical Center is supported by multiple grants from federal, foundation, and industry research sponsors. More information is available upon request.

Figures

Figure 1.
Figure 1.
Health plans’ use of coverage restrictions over time: Specialty Drug Evidence and Coverage (SPEC) database. Inclusion criteria require US commercial payers to have a specialty drug coverage policy present at least 1 time point during the study period (2017–2021), but because coverage can change year over year, this caused the number of specialty coverage policies (the denominator) to increase over time (n = 4418 in 2017, n = 4998 in 2021).
See this image and copyright information in PMC

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