Consistency of Specialty Drug Coverage in Payers’ Benefit Designs

Depending on formulation, site of administration, and other factors, specialty drugs may be covered by health plans in either their medical or pharmacy benefits. This study aimed to evaluate the consistency of plans’ medical and pharmacy coverage policies for specialty drugs.

Study data were derived from the Specialty Drug Evidence and Coverage (SPEC) Database, which includes specialty drug coverage policies issued by 17 of the largest US commercial health plans (as of 2020). Health plans were required to offer both medical and pharmacy policies to be eligible for inclusion in the study. Once included, drugs for which health plans issued both medical and pharmacy policies were identified as “medical-pharmacy policy pairs.” For each pair, policies were compared, while accounting for the following criteria: patient subgroups (certain eligibility criteria), prescriber requirements (eg, prescription written by specialist), and step therapy protocols (patients must first fail “preferred” treatments). Medical-pharmacy policy pairs were deemed to be inconsistent if criteria for drug coverage were different (eg, the pharmacy policy included a step therapy protocol, but the medical policy did not).

A total of 1619 medical-pharmacy policy pairs—representing 287 drugs across 8 plans—were identified. Eighty-six percent of pairs were found to be consistent (1386 of 1619), and 14% (233 of 1619) were found to be inconsistent. Inconsistencies were most often found to be differences in plans’ step therapy protocols (184/233), followed by prescriber requirements (52/233), and patient subgroup restrictions (25/233). Forty pairs had multiple inconsistencies. In 125 of 233 inconsistent pairs, pharmacy policies were found to be more restrictive than their adjacent medical policies. Though some health plans were found to have fully consistent medical-pharmacy policy pairs (up to 100%), other health plans were found to have an abundance of inconsistent pairs (as low as 40%).

Although commercial health plans’ medical and pharmacy specialty drug coverage policies tended to be relatively consistent, substantial incongruencies between medical and pharmacy policies were found in 14% of the health plans evaluated in the study. The authors concluded that inconsistent medical and pharmacy benefits could complicate and potentially hinder patient access to specialty drugs.

Source:

Levine A, Kauf T, O’Sullivan A, et al. Does specialty drug coverage vary between health plans’ medical and pharmacy benefit policies? Presented at: 2022 Academy of Managed Care Pharmacy Nexus Annual Meeting; October 11-14, 2022; National Harbor, MD. Poster F4.