OBJECTIVES

Because health plans formulate their own coverage decisions, how they cover medical interventions can vary. In this study we examined how the largest US commercial health plans cover products indicated for hemophilia A (HA).

METHODS

We identified coverage decisions for HA treatments in the Specialty Drug Evidence and Coverage (SPEC) Database, which includes information on how 17 of the largest US commercial health plans (>60% of commercially covered lives; 7 national plans, 10 regional plans) cover specialty products. When a treatment was not included in SPEC, we obtained the necessary information from the health plans’ websites. Next, for each product, we compared the coverage decisions with the product’s FDA labeled indication. We categorized each decision as: equivalent to the labeled indication, more restrictive, less restrictive, or mixed (i.e., more restrictive than the labeled indication in one way, but less restrictive in another). Finally, we categorized each coverage restriction as a step therapy protocol, patient subgroup, or prescriber requirement (a specific physician must prescribe the drug).

RESULTS

We examined 297 coverage decisions for 26 products. We categorized 51% of decisions as more restrictive, 7% as less restrictive, 35% as equivalent, and 7% as ‘mixed’. In restricted decisions, plans most frequently applied patient subgroups (82% of restricted decisions), followed by step therapy protocols (29%). Plans most often applied coverage restrictions in decisions for a newer treatment, emicizumab (12/15 decisions), followed by recombinant antihemophilic factor (10/13 decisions). Plans least often applied restrictions in their decisions for one recombinant factor VIIa coagulation product (1/13 decisions) and one porcine sequence recombinant antihemophilic factor (1/12 decisions). No product was covered consistently across all 17 plans.

CONCLUSIONS

We found notable variation in how US commercial health plans cover HA treatments, which has important implications for patients’ access to these treatments.