Characterizing health plan evidence review practices.

Area of Science:

• Health economics
• Pharmaceutical policy
• Evidence-based medicine

Background:

• Health plans utilize coverage policies to manage specialty drug access.
• Practice guidelines advocate for comprehensive and updated evidence supporting these policies.

Purpose of the Study:

• To assess the update frequency of health plan coverage criteria and supporting evidence.
• To analyze how health plans cite relevant literature in their drug coverage policies.

Main Methods:

• Reviewed coverage policies from 17 US commercial health plans (August 2017 & 2019).
• Identified drug-indication pairs and tracked policy reissuance, criterion changes, and evidence updates.
• Conducted systematic literature searches for 20 drug-indication pairs to assess cited evidence comprehensiveness.

Main Results:

• 97% of drug-indication pair policies were reissued over two years.
• 69% of revised policies updated only cited evidence; 15% updated both criteria and evidence.
• Plans cited only 5.3% of relevant literature, with health technology assessments, RCTs, and systematic reviews cited most comprehensively.

Conclusions:

• Most specialty drug coverage policies are reissued within a two-year timeframe.
• Revisions to coverage criteria are typically accompanied by updates to cited evidence.
• Health plans demonstrate more comprehensive citation of health technology assessments, RCTs, and systematic reviews.