ISSUE:

Health plans’ drug coverage policies play a fundamental role in guiding patients’ access to specialty therapies. Research has found that health plans are imposing coverage restrictions (e.g., step therapy protocols, patient subgroup restrictions, etc.) in their specialty drug coverage policies more often. This panel will provide a forum to discuss the potential reasons for this trend, and its consequences for patients and other health care stakeholders.

OVERVIEW:

Rising costs mean that health plans face a challenge to provide their enrollees with appropriate access to specialty drugs. James Chambers will moderate the panel and will frame the issue by summarizing new research that has found that among US commercial health plans’ specialty drug coverage has become increasingly restrictive. This empirical research, which tracked roughly 5,000 plan coverage policies for 200 specialty therapies over a five-year period, found that the percentage of coverage policies with utilization management criteria increased from 39% in 2017 to 52% in 2021. Plans’ greater use of step therapy protocols is one factor driving this trend. C. Bernie Good will provide a health plan perspective, describing the challenges encountered by health plans, and the various approaches plans are taking to rise to these challenges, including the use of innovative value based contracts for pharmaceuticals. Rochelle Henderson will provide an industry perspective and will give an overview of how product manufacturers interact with health plans and their evidence generation practices. Panelists’ presentations will be limited to three PowerPoint slides (a maximum of 5 minutes), after which the moderator will encourage debate through Q&A and audience participation.