December 4, 2023

Traditionally, doctor administered specialty prescribed drugs are lined by a affected person’s medical profit and oral medicines are lined by the pharmacy profit. More and more, nonetheless, specialty prescribed drugs are being lined by pharmaceutical profit. Does this make a distinction? Does medical vs. pharmacy protection of medicine affect affected person entry?

A latest paper by Levine et al. (2023) goals to reply this query. They use information from the Tufts Medical Heart Specialty Drug Proof and Protection Database. This database contains protection insurance policies from 17 massive US business well being plans. They discover the next:

RESULTS: Eight plans issued separate medical and pharmacy profit protection insurance policies for a similar specialty drug and indication. Amongst these 8 plans, we recognized 1,619 medical-pharmacy coverage pairs. Eighty-six % of pairs had been concordant (1,386/1,619), and 14% had been discordant (233/1,619). Discordance was most frequently resulting from variations in plans’ utility of step remedy protocols (184/233), adopted by prescriber necessities (52/233) and affected person subgroups (25/233). Forty pairs had been discordant in a number of methods. Of discordant pairs, medical insurance policies had been extra restrictive 41% (96/233) of the time; pharmacy insurance policies had been extra restrictive 54% (125/233) of the time; 5% of the time (12/233), the medical coverage was extra restrictive in some methods, however the pharmacy coverage was extra restrictive in others. General, plans imposed protection restrictions of their medical and pharmacy insurance policies with related frequencies.
CONCLUSIONS: Industrial well being plans’ medical and pharmacy protection insurance policies for a similar specialty medication tended to be concordant, though we discovered protection standards to be discordant 14% of the time. Medical and pharmacy insurance policies which can be inconsistent of their protection standards and restrictions complicate, and doubtlessly hinder, sufferers’ entry to specialty medication.

As proven within the desk beneath, the variety of step edits different throughout the medial vs. pharmacy profit.

Variations in Variety of Step Edits Between Step-Discordant Medical and Pharmacy Profit Coverage Pairs (n = 184)

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