Most of the largest health plans in the U.S. generally provide “fair access” to 19 treatments for a handful of serious diseases, although transparent coverage information is often lacking for some medicines, a new analysis found.
Almost uniformly, the 18 health plans and benefit managers examined make the medications available fairly when judged on three criteria: prescriber restrictions, eligibility based on clinical data, and step therapy, which requires patients to try other medicines before an insurer will approve a prescription.
However, the plans did not score quite as well on a fourth criteria: cost sharing, which is the portion of expenses paid by insured individuals. Although there is a caveat worth noting: This particular metric was determined based on a smaller subset of just six medicines that were deemed to be fairly priced based on a cost-effectiveness assessment.
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