Specialty Drug Coverage Varies Widely Among Largest US Commercial Insurers

Study finds that specialty drug coverage policies are mostly inconsistent across health plans and many treatments have multiple restrictions to access.

A recent Health Affairs study indicated that specialty drug coverage and reimbursement varies substantially across 17 of the 20 largest US insurers, with only 15.9% of the drug coverage policies consistent across commercial health plans.

Even among medications that were covered, many of the treatments had multiple restrictions in place prior to patients being able to access them.

For the study, which was conducted by the National Pharmaceutical Council and the Center for Evaluation of Value and Risk in Health at Tufts Medical Center, the authors analyzed specialty drug coverage decisions issued by payers to examine variation in how insurers covered specialty medications and consistency with indications approved by the FDA.

Information on drug insurer coverage decisions was collected through a systematic review contained within the Tufts Medical Center Specialty Drug Evidence and Coverage Database.

Of the 3417 decisions analyzed, 16% of the 302 drug-indication pairs were covered the same way by 75% of the plans, with 52% of decisions consistent with the FDA label, 9% less restrictive, 2% mixed, and 33% more restrictive. Five percent of the pairs were not covered.

Less than half (48%) of all drug coverage decisions were consistent across most of the health plans.

According to the study, there were multiple coverage restrictions in 22.5% of decisions. The most common restriction types were:

  • Step edits: when a prior treatment must be proven ineffective before the plan will cover the treatment (73%).
  • Limitations on types of physicians who could prescribe the medication (31%).
  • Restrictions to certain patient subgroups (16%).

Coverage was less likely to be restricted for treatments indicated for pediatric populations, rare diseases, or cancer. Other factors related to less restrictive coverage included medications administered by physicians, absence of safety warnings, time on the market, lack of alternatives, and drugs approved under an FDA expedited review program.

Related Coverage: Newer Specialty Drugs Require Payers to Revise Coverage Strategies

“Variation in coverage may substantially influence patient access to specialty medicines,” study author Jennifer Graff, PharmD, vice president of Comparative Effectiveness Research at the National Pharmaceutical Council, said in a statement. “For patients switching between insurers or employers, differences in plans’ coverage decisions may result in care disruptions. It also requires that physicians tailor care not only to diverse patients, but also to multiple insurance plans that provide health care coverage.”

The study authors concluded that greater transparency with the evidence used to determine coverage decisions would be beneficial to patients, providers, and manufacturers.


Study of US Commercial Health Plans Shows Widespread Variation in Coverage and Reimbursement for Specialty Medicines [news release]. National Pharmaceutical Council’s website. https://www.npcnow.org/publication/study-us-commercial-health-plans-shows-widespread-variation-coverage-and-reimbursement. Accessed July 13, 2018.