Objective: Health plans often cover specialty drugs in both their medical and pharmacy benefit policies. We examined the consistency of plans’ medical and pharmacy drug coverage policies.

Methods: We used the Specialty Drug Evidence and Coverage (SPEC) Database, which includes specialty drug coverage policies issued by 17 of the largest US commercial health plans (policies were current August 2020). We included plans that issued both medical and pharmacy policies. We then identified drugs with “medical-pharmacy policy pairs,” i.e., drugs for which plans issued both a medical and a pharmacy policy. For these pairs, we compared plans’ policies while accounting for the following coverage criteria: patient subgroups (patients must meet certain clinical criteria), prescriber requirements (a specialist must prescribe the drug), and step therapy protocols (patients must first fail alternative treatments). We considered medical-pharmacy policy pairs to be inconsistent if coverage criteria differed, e.g., the medical policy included a prescriber requirement but the pharmacy policy did not.

Results: We identified 1619 medical-pharmacy policy pairs (representing 287 drugs across 8 plans). Eighty-seven percent of pairs were consistent (1401/1619), and 13% were inconsistent (218/1619). Inconsistency was most often due to differences in plans’ application of step therapy protocols (184/219), followed by prescriber requirements (37/219) and patient subgroups (24/219). Twenty-nine pairs (of 219) were inconsistent in multiple ways. For 116/219 inconsistent pairs, a plan’s pharmacy policy was more restrictive than its medical policy. Plans varied widely with respect to the proportion of their medical-pharmacy policy pairs that were consistent (range 6% to 100%).

Conclusions: Commercial health plans’ medical and pharmacy specialty drugs coverage policies tended to be consistent, although we found that coverage criteria differed in important ways in 13% of the medical-pharmacy policy pairs. Inconsistent medical and pharmacy policies complicate, and potentially hinder, patients’ access to specialty drugs.