Alignment of Commercial Health Plan Specialty Drug Utilization Management Criteria With Clinical Treatment Guidelines​

AUTHORS

Julia Rucker, BA, Molly Beinfeld, MPH, Katherine Clifford, MPH, and James Chambers, PhD, MPharm, of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center / Jonathan D. Campbell, PhD, MS, and James Motyka, PharmD, of the National Pharmaceutical Council

OVERVIEW

Utilization management (UM) criteria are pivotal in regulating patient access to specialty drugs. Despite calls for greater transparency, a significant gap remains in understanding how plans derive UM criteria from clinical treatment guidelines. This study investigates
the relationship between commercial health plans’ UM criteria and the favorability of clinical guidelines.

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