Commercial Health Plan Prescriber Requirements Vary Greatly Among Insurers

Many United States health plans implement utilization management tools like specific prescriber requirements, especially for specialty drug coverage decisions. These stipulations ensure patients are prescribed appropriate medications by qualified physicians. However, little data exists on how these requirements vary health plan to health plan, and researchers sought to better understand how the potential variability affects patient access.

Kelly Lenahan, MPH, and coresearchers, presented study data at AMCP 2021 in which they examined specialty drug coverage decision data from the Tufts Medical Center Specialty Drug and Evidence (SPEC) database for 17 large US commercial health plans. The SPEC database includes utilization criteria from health plans for coverage decisions and information on prescriber requirements.

Ms Lenahan and coresearchers specifically reviewed coverage decisions that were active in 2020 and categorized prescriber requirements as follows:

• prescribed by or in consultation with a specialist (eg, a neurologist);
• prescribed by a specialist; and
• prescribed by a specialist with particular expertise (eg, a neurologist with expertise in spinal muscular atrophy).

The researchers then compared the frequency at which plans applied prescriber requirements by health plan and different drug attributes.

According to the findings, 22% of health plan coverage decisions had prescriber requirements applied (1,791/8,140 decisions; range=0.2% to 86%). Other prescriber requirements implemented by health plans were specialist consultation (17%), prescribing by a specialist (4%), and prescribing by a specialist with particular expertise (0.6%).

Researchers found that prescriber requirements were more prevalent for noncancer treatments (28.5%) compared to cancer treatments (14.5%). More requirements were applied for drugs indicated for pediatric populations than those indicated for adults (26.4% vs 21.2%). Additionally, drugs with black box warnings (23.7%) had more requirement instances than those without (20.6%).  

“US commercial health plans vary widely with respect to how often they apply prescriber requirements, with some applying prescriber requirements in almost all their decisions, while others rarely doing so,” concluded Ms Lenahan and colleagues.

—Edan Stanley

Reference:
Lenahan K, Gertler R, Panzer A, Chambers J. Do US commercial health plans apply prescriber requirements in their specialty drug coverage policies with different frequencies? Poster presented at: AMCP 2021, April 12-16, 2021; Virtual.