VARIATION IN COMMERCIAL HEALTH PLAN COVERAGE OF ATOPIC DERMATITIS THERAPIES
Author(s)
Claire H. Brennan, BA, Sophie E. Knox, MSc, BSc, Daniel E. Enright, MS, Molly T. Beinfeld, MPH, James D. Chambers, MSc, PhD;
Tufts Medical Center, The Center for the Evaluation of Value and Risk in Health, Boston, MA, USA
Tufts Medical Center, The Center for the Evaluation of Value and Risk in Health, Boston, MA, USA
OBJECTIVES: The 2017 approval of dupilumab, followed by additional specialty therapies, reshaped the treatment options for atopic dermatitis (AD). This study evaluates US commercial health plan coverage of specialty therapies for AD.
METHODS: We used the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database, which contains specialty drug coverage policies from 18 large US commercial health plans. We identified coverage policies for seven drugs indicated for AD active in August 2025. Researchers reviewed policies to assess the use of clinical requirements, step therapy, and prescriber requirements.
RESULTS: Among 89 active policies, plans varied in their use of clinical requirements, step therapy, and prescriber requirements. Overall, 52.8% of policies required patients to meet specific diagnostic thresholds, including minimum affected body surface area (BSA) and disease-severity scale scores. Among these policies, 56.8% required only a minimum BSA (e.g., involvement of at least 10% of BSA), whereas 43.2% required patients to meet both a minimum BSA and a threshold on a disease-severity scale (e.g., a score of 3 on the Investigator’s Global Assessment). Step therapy was imposed in all policies. Of these, 34.8% aligned with the typical FDA label requiring a step through topical therapy, while 65.2% imposed one to five additional steps beyond the label. Among policies with additional steps, 12.1% (7/58) required patients to step through a preferred branded product. Prescriber requirements were common, with 77.5% of policies requiring consultation with, or prescription by, a dermatologist. Access criteria varied across plans. For example, 2 plans imposed step requirements beyond the FDA label in fewer than 25% of policies, whereas 7 plans did so in more than 75% of policies.
CONCLUSIONS: US commercial health plans frequently require patients to meet clinical criteria to access specialty drugs for AD, though the extent of these requirements varies substantially across plans, potentially resulting in differential patient access.
METHODS: We used the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database, which contains specialty drug coverage policies from 18 large US commercial health plans. We identified coverage policies for seven drugs indicated for AD active in August 2025. Researchers reviewed policies to assess the use of clinical requirements, step therapy, and prescriber requirements.
RESULTS: Among 89 active policies, plans varied in their use of clinical requirements, step therapy, and prescriber requirements. Overall, 52.8% of policies required patients to meet specific diagnostic thresholds, including minimum affected body surface area (BSA) and disease-severity scale scores. Among these policies, 56.8% required only a minimum BSA (e.g., involvement of at least 10% of BSA), whereas 43.2% required patients to meet both a minimum BSA and a threshold on a disease-severity scale (e.g., a score of 3 on the Investigator’s Global Assessment). Step therapy was imposed in all policies. Of these, 34.8% aligned with the typical FDA label requiring a step through topical therapy, while 65.2% imposed one to five additional steps beyond the label. Among policies with additional steps, 12.1% (7/58) required patients to step through a preferred branded product. Prescriber requirements were common, with 77.5% of policies requiring consultation with, or prescription by, a dermatologist. Access criteria varied across plans. For example, 2 plans imposed step requirements beyond the FDA label in fewer than 25% of policies, whereas 7 plans did so in more than 75% of policies.
CONCLUSIONS: US commercial health plans frequently require patients to meet clinical criteria to access specialty drugs for AD, though the extent of these requirements varies substantially across plans, potentially resulting in differential patient access.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR147
Topic
Health Policy & Regulatory
Topic Subcategory
Insurance Systems & National Health Care, Reimbursement & Access Policy
Disease
No Additional Disease & Conditions/Specialized Treatment Areas, SDC: Sensory System Disorders (Ear, Eye, Dental, Skin)