Historically, physician-administered specialty drugs were covered by the patient’s medical benefit, and oral medications were covered by the pharmacy benefit. However, more and more specialty medicines are included in the scope of drug benefits. Does it make a difference? Does medical versus pharmacy coverage for a drug affect patient use?
A recently published paper Levin et al. (2023) aims to answer this question. They used data from the Tufts Medical Center’s Specialty Drug Evidence and Coverage database. The database includes underwriting policies for 17 large U.S. commercial health plans. They found the following:
result: Eight plans issued separate medical and pharmacy benefit insurance policies for the same specialty drug and indication. Across the eight programs, we identified 1,619 pharmaceutical policy pairs. 86% of the pairs were concordant (1,386/1,619) and 14% were discordant (233/1,619). The most common reason for inconsistency was differences in program application of step-by-step regimens (184/233), followed by prescriber requirements (52/233) and patient subgroups (25/233). Forty pairs are inconsistent in many ways. Among inconsistent pairs, medical policy was more restrictive 41% (96/233) of the time; drug policy was more restrictive 54% (125/233) of the time; and medical policy was more restrictive 5% of the time (12/233) Some aspects are more restrictive, but pharmacy policies are more restrictive in other aspects. Overall, plans imposed coverage limits with similar frequency in their medical and pharmacy policies.
in conclusion: Commercial health plans tended to have consistent medical and pharmacy coverage policies for the same specialty drug, although we found that coverage standards were inconsistent in 14% of cases. Inconsistent coverage standards and limitations in medical and pharmacy policies can complicate and potentially prevent patient access to specialty medications.
As shown in the table below, the number of step edits varies for different medical benefits and drug benefits.
The full article is here.
