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Rucker JA, Beinfeld MT, Jenkins NB, Enright DE, Henderson RR, Chambers JD. Commercial coverage of specialty drugs, 2017-2021. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad030. [PMID: 38756241 PMCID: PMC10986192 DOI: 10.1093/haschl/qxad030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/14/2023] [Accepted: 08/02/2023] [Indexed: 05/18/2024]
Abstract
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 approximately 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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Affiliation(s)
- Julia A Rucker
- Tufts Medical Center, Center for the Evaluation of Value and Risk in Health,Boston, MA 02111, United States
| | - Molly T Beinfeld
- Tufts Medical Center, Center for the Evaluation of Value and Risk in Health,Boston, MA 02111, United States
| | - Nola B Jenkins
- Tufts Medical Center, Center for the Evaluation of Value and Risk in Health,Boston, MA 02111, United States
| | - Daniel E Enright
- Tufts Medical Center, Center for the Evaluation of Value and Risk in Health,Boston, MA 02111, United States
| | | | - James D Chambers
- Tufts Medical Center, Center for the Evaluation of Value and Risk in Health,Boston, MA 02111, United States
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Jenkins NB, Rucker JA, Klimchak AC, Sedita LE, Chambers JD. Commercial health plans use of patient subgroup restrictions: An analysis of orphan and FDA-expedited programs. J Manag Care Spec Pharm 2023; 29:472-479. [PMID: 36864544 PMCID: PMC10394186 DOI: 10.18553/jmcp.2023.22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND: Health plans apply utilization management criteria to guide their enrollees' access to prescription drugs. Patient subgroup restrictions (ie, clinical prerequisites for drug coverage) are a form of utilization management that have not been thoroughly investigated. OBJECTIVE: To examine the frequency with which large US commercial health plans impose patient subgroup restrictions beyond the US Food and Drug Administration (FDA) label in their coverage policies for orphan drugs and for drugs included in 1 or more FDA-expedited programs. To determine how consistently these patient subgroup restrictions align with eligibility criteria specified in each drug's pivotal clinical trial(s). METHODS: The Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database was used, which includes coverage policies issued by 17 large US commercial health plans. SPEC contained 3,786 orphan drug policies and 4,027 FDA-expedited drug policies (current as of December 2020). SPEC data on plans' patient subgroup restrictions were assessed for the first objective. Each patient subgroup restriction was benchmarked against the corresponding eligibility criteria for a drug's pivotal clinical trial(s) for the second objective. To do so, the "Clinical Studies" section of the drug's FDA label was reviewed or, if necessary, the published manuscript describing the drug's pivotal trial(s). Patient subgroup restrictions were categorized as follows: (1) "consistent," the restriction and trial eligibility criterion are equivalent; (2) "same measure, more stringent," the restriction and trial eligibility criteria depend on the same measure, but the plan coverage is more restrictive; (3) "same measure, less stringent," the restriction and trial eligibility criteria depend on the same measure, but the plan coverage is less restrictive; and (4) "not consistent," the restriction and trial eligibility criteria depend on different measures. RESULTS: Health plans imposed patient subgroup restrictions in 20.2% of orphan drug policies (frequency varied by health plan, 11.7%-36.6%), and in 21.8% of FDA-expedited drug policies (frequency varied by health plan, 11.1%-47.9%). Of the 936 patient subgroup restrictions in orphan drug policies, 60.3% were categorized as consistent; 7.3% as same measure, more stringent; 12.0% as same measure, less stringent; and 20.5% as not consistent. Of the 1,070 patient subgroup restrictions in FDA-expedited drug policies, 57.5% were categorized as consistent; 6.7% as same measure, more stringent; 16.0% as same measure, less stringent; and 19.8% as not consistent. CONCLUSIONS: Patient subgroup restrictions for orphan drugs and FDA-expedited programs varied substantially across health plans, potentially resulting in inconsistent access to a given therapy across the approved patient population. Patient subgroup restrictions tend to be consistent with eligibility criteria specified in pivotal clinical trials. DISCLOSURES: This study was funded by Sarepta Therapeutics, Inc. Alexa C Klimchak and Lauren E Sedita are employees of Sarepta Therapeutics, Inc., and may own stock/options in the company.
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Affiliation(s)
- Nola B Jenkins
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Julia A Rucker
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | | | | | - James D Chambers
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
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Gupta A, Arora N, Haque W, Hussaini SMQ, Sedhom R, Blaes AH, Dusetzina SB. Out-of-pocket costs of oral anticancer drugs for Medicare beneficiaries vary by strength and formulation. J Geriatr Oncol 2023; 14:101386. [PMID: 36229377 DOI: 10.1016/j.jgo.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/27/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Arjun Gupta
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, United States of America.
| | - Nivedita Arora
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, United States of America
| | - Waqas Haque
- Department of Internal Medicine, New York University Langone Health, New York, NY, United States of America
| | - S M Qasim Hussaini
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, MD, United States of America
| | - Ramy Sedhom
- Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, United States of America; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Anne H Blaes
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, United States of America
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States of America; Vanderbilt-Ingram Cancer Center, Nashville, TN, United States of America
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Etteldorf A, Sedhom R, Rotolo SM, Vogel RI, Booth CM, Blaes AH, Virnig BA, Dusetzina SB, Gupta A. The least costly pharmacy for cancer supportive care medications over time: the logistic toxicity of playing catch up. Support Care Cancer 2023; 31:3. [PMID: 36512134 PMCID: PMC9745713 DOI: 10.1007/s00520-022-07472-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE No single pharmacy in an urban zip code is consistently the least expensive across medications. If medication prices change differently across pharmacies, patients and clinicians will face challenges accessing affordable medications when refilling medications. This is especially pertinent to people with cancer with multiple fills of supportive care medications over time. We evaluated if the lowest-priced pharmacy for a formulation remains the lowest-priced over time. METHODS We compiled generic medications used to manage nausea/vomiting (14 formulations) and anorexia/cachexia (12 formulations). We extracted discounted prices in October 2021 and again in March 2022 for a typical fill at 8 pharmacies in Minneapolis, Minnesota, USA (zip code 55,414) using GoodRx.com. We examined how prices changed across formulations and pharmacies over time. RESULTS Data were available for all 208 possible pharmacy-formulation combinations (8 pharmacies × 26 formulations). For 172 (83%) of the 208 pharmacy-formulation combinations, the March 2022 price was within 20% of the October 2021 price. Across pharmacy-formulation combinations, the price change over time ranged from - 76 to + 292%. For 12 (46%) of the 26 formulations, at least one pharmacy with the lowest price in October 2021 no longer was the least costly in March 2022. For one formulation (dronabinol tablets), the least expensive pharmacy became the most expensive, with an absolute and relative price increase of a fill of $22 and 85%. CONCLUSION For almost half of formulations studied, at least one pharmacy with the lowest price was no longer the least costly a few months later. The lowest price for a formulation (across pharmacies) could also change considerably. Thus, even if a patient accesses the least expensive pharmacy for a medication, they may need to re-check prices across all pharmacies with each subsequent fill to access the lowest prices. In addition to safety concerns, directing medications to and accessing medications at multiple pharmacies can add time and logistic toxicity to patients with cancer, their care partners, prescribers, and pharmacy teams.
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Affiliation(s)
- Andrew Etteldorf
- Division of Hematology, Oncology & Transplantation, University of Minnesota, 516 Delaware Street SE, MMC 480, PWB 14-100, Minneapolis, MN 55455 USA
| | - Ramy Sedhom
- University of Pennsylvania, Philadelphia, PA USA
| | | | - Rachel I. Vogel
- Division of Hematology, Oncology & Transplantation, University of Minnesota, 516 Delaware Street SE, MMC 480, PWB 14-100, Minneapolis, MN 55455 USA
| | | | - Anne H. Blaes
- Division of Hematology, Oncology & Transplantation, University of Minnesota, 516 Delaware Street SE, MMC 480, PWB 14-100, Minneapolis, MN 55455 USA
| | - Beth A. Virnig
- Division of Hematology, Oncology & Transplantation, University of Minnesota, 516 Delaware Street SE, MMC 480, PWB 14-100, Minneapolis, MN 55455 USA
| | | | - Arjun Gupta
- Division of Hematology, Oncology & Transplantation, University of Minnesota, 516 Delaware Street SE, MMC 480, PWB 14-100, Minneapolis, MN 55455 USA
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