Use of prescriber requirements among US commercial health plans

Lenahan, K.; Panzer, Ari D; Gertler, R.M.; Chambers, James D.

doi:10.18553/jmcp.2021.27.12.1757

Cited by 5 publications

(2 citation statements)

References 8 publications

(8 reference statements)

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“…A prescriber requirement stipulating that a physician with sufficient expertise prescribes a particular drug can promote appropriate use of a therapy, but it could also delay or impede access to care. 5 …”

Section: Discussionmentioning

confidence: 99%

Commercial coverage of specialty drugs, 2017–2021

Rucker

Beinfeld

Jenkins

et al. 2023

Health Affairs Scholar

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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 roughly 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.

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Section: Discussionmentioning

confidence: 99%

Commercial coverage of specialty drugs, 2017–2021

Rucker

Beinfeld

Jenkins

et al. 2023

Health Affairs Scholar

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“…Such requirements may be necessary when specialized training is required for the safe and effective use of a drug. However, there is a risk that prescriber requirements delay patients’ access to care, make care more expensive, and create access challenges, particularly for some rurally located patients and those without access to physicians with the required expertise [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Patients’ access to rare neuromuscular disease therapies varies across US private insurers

Margaretos

Bawa²,

Engmann³

et al. 2022

Orphanet J Rare Dis

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Background The extent to which different US private insurers require their enrollees to meet the same coverage criteria before gaining access to treatment is unclear. Our objective was to scrutinize the patient access criteria imposed by US private insurers for a set of rare neuromuscular disease (NMD) disease-modifying therapies (DMTs). Methods We examined coverage policies issued by 17 large US private insurers for the following NMD treatments: nusinersen and onasemnogene abeparvovec for spinal muscular atrophy, edaravone for amyotrophic lateral sclerosis, and eteplirsen for Duchenne muscular dystrophy. We reviewed the plans’ coverage policies and identified the patient access criteria, including clinical prerequisites, step therapy protocols, and prescriber requirements. We compared the plans’ patient access criteria with the therapies’ US Food and Drug Administration (FDA)-labeled indications. Results The included insurers issued 65 coverage policies for the included therapies. Plans imposed coverage restrictions beyond the FDA-approved indications in 60 coverage policies; plans did not cover eteplirsen in five policies. No therapy was covered the same way by all insurers. Plans applied clinical criteria beyond the FDA label indication in 56 policies and step therapy protocols in three policies. Plans required that a neurologist prescribe the therapy in 37 policies, 22 of which required the neurologist to have expertise in the particular disease. Plans often required patients to suffer from symptoms of particular severity; e.g. for eteplirsen, plans differed in their 6-min walk test requirements; for edaravone, some plans required that patients had normal respiratory function, while others required only that patients did not require ventilation; for nusinersen and onasemnogene abeparvovec, plans differed in the number of SMN2 gene copies they required patients to have (SMN2 copy number is correlated with disease severity). Conclusions The evaluated large US private insurers tended to impose coverage restrictions beyond the FDA label indication for the included set of rare NMD DMTs. Plans rarely applied the same patient access criteria in their coverage policies for the same products. Inconsistent coverage criteria mean that patients with different insurers have variable access to the same therapies across insurers.

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