Health Insurance Pharmaceuticals

Variation in specialty drug coverage in the U.S.

The U.S. has a decentralized health care system.  This means that depending on your health plan, you may have more or less generous coverage.  But how does coverage vary across plans?  A recent paper by Chambers et al. (2018) looks specifically at coverage of specialty drugs.  Using the Tufts Medical Center’s Specialty Drug Evidence and Coverage Database, a database of US health plans’ specialty drug coverage decisions, the authors find that:

Across 3,417 decisions, 16 percent of the 302 drug-indication pairs were covered the same way by all of the health plans, and 48 percent were covered the same way by 75 percent of the plans. Specifically, 52 percent of the decisions were consistent with the FDA label, 9 percent less restrictive, 2 percent mixed (less restrictive in some ways but more restrictive in others), and 33 percent more restrictive, while 5 percent of the pairs were not covered. Health plans restricted coverage of drugs indicated for cancer less often than they did coverage of drugs indicated for other diseases.

Published in this month’s edition of Health Affairs.


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