Driving Evidence-Based Health Plan Coverage by Recognizing Gaps, Updating Practices

Overview

Will health plans cover medications if the underlying clinical and economic evidence supports access?

A recent study by the National Pharmaceutical Council and the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center, published in Health Affairs, explores how health plans use evidence to inform coverage decisions. The study aims to understand potential factors behind findings from earlier research that showed insurance coverage and reimbursement for specialty medications varied substantially, with only 15.9 percent of drug coverage policies consistent across the largest U.S. commercial health plans.

Why does it matter? Despite the broad push for evidence-based care, a patient's access to the best treatment may be compromised when coverage decisions don't draw on the best available evidence and require physicians to tailor care around insurance coverage.

Learning Objectives

At the conclusion of the session, participants will be able to describe:

• The gaps between evidence and coverage policies, and the variation across health plans in the quantity, breadth and types of clinical and economic evidence used to inform coverage policies.
• The variations in coverage for specialty medicines by U.S. commercial health plans and the challenges these variations present to patients, clinicians and the health care system as a whole.
• The current state of formulary development practices and priority considerations for stakeholders working to update formulary practices

Presenters

• Jennifer Graff, PharmD, Vice President, Comparative Effectiveness Research, NPC
• James Chambers, PhD, MPharm, MSc, Associate Professor of Medicine, The Tufts Medical Center Institute for Clinical Research and Health Policy Studies
• Scott Thompson, Area President, Gallagher Research and Insights

The slides from this presentation are available as a PDF.

Audience: Stakeholders including employers, accreditation organizations, insurers, health plans, prescription benefit managers, patients, life sciences and health technology assessment.