RA Drug Coverage Inconsistent Among Largest Private Payers

According to a poster presentation at AMCP Nexus 2016, the country’s largest private health care payers cover rheumatoid arthritis (RA) drugs inconsistently and use different evidence to support their coverage policy decisions. 

“Because health care payers conduct their own assessments, how they cover drugs can vary, which in turn can affect patients’ access to care,” James D Chambers, PhD, MPharm, MSc, assistant professor of medicine at the Tufts Medical Center Institute for Clinical Research and Health Policy Studies, and colleagues wrote.  Their research sought to “examine how the largest private health care payers cover RA drugs and to determine what evidence they report reviewing in their coverage policies.”

The researchers examined current coverage policies for RA drugs using the websites of the country’s largest private payers.  In order to categorize their findings, the researchers classified coverage policies into three groups; those that covered RA drugs for the labeled indication, those that were more restrictive than the labeled indication, those that were less restrictive than the labeled indication, and those that were mixed. They then compared each policy to the American College of Rheumatology’s (ACR) 2012 treatment recommendations. 

Finally, each policy was reviewed to determine which evidence payers used to support how restrictive their policies were. Evidence bases included randomized controlled trials, other clinical studies, health technology assessments, clinical reviews, cost-effectiveness analyses, and clinical guidelines.

In total, the researchers identified 10 payers with 94 coverage plans for 10 RA drugs.

Study results showed that 69% of coverage policies were more restrictive than the FDA indications, 15% were equivalent, 3% were less restrictive, and 13% were mixed. The researchers also found that only 34% of coverage policies were consistent with the ACR’s recommendations, while 33% were more restrictive and 17% were less restrictive.

The researchers noted that evidence used to support these restrictions varied, with randomized controlled trials reported by payers most frequently.

“The included payers most often covered RA drugs more restrictively than the corresponding FDA labeled indication and the ACR’s treatment recommendations and reported reviewing a different evidence base in their coverage policies,” Dr Chambers and colleagues concluded. —David Costill