Presentation (CTI)

OBJECTIVES: Health plan coverage policies play an important role in determining patients’ access to specialty drugs. Complex and lengthy policies may introduce administrative demands that affect prescribing processes, potentially delaying treatment initiation and discouraging clinicians from prescribing certain therapies. We aimed to evaluate how the complexity of specialty drug coverage policies has changed over time.
METHODS: We used the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database, which tracks coverage policies from the largest US commercial health plans. To ensure comparability across years, we restricted the analysis to the same 360 drug-indication pairs and the same 16 health plans included in SPEC each year from 2017-2024. We assessed complexity using four measures: (1) number of documents per coverage policy, (2) policy length (word count of text defining the eligible patient population), (3) number of individual coverage criteria (approximated by the count of separately listed requirements in the eligibility text), and (4) inclusion of pre-authorization documentation requirements.
RESULTS: Across all years, the analysis included approximately 4,550 specialty drug coverage policies annually, with minor year-to-year variation. Between 2017 and 2024, the share of specialty drug coverage policies with multiple documents increased from 0.3% to 30.9% and the average number of documents per policy rose from 1.00 to 1.39. Mean policy length increased from 109.8 to 272.6 words. The mean number of individual coverage criteria also increased, from 7.7 to 18.3. The proportion of policies with pre-authorization documentation requirements rose from 9.2% to 27.9%.
CONCLUSIONS: Specialty drug coverage policies have become increasingly complex over time. Health plans now issue more documents per policy, use longer coverage language with a greater number of specific criteria, and are more likely to require pre-authorization documentation. Together, these factors increase administrative burden in navigating approval processes and may create barriers to patient access.