In US healthcare, individual payers create their own prescription drug coverage policies. This can lead to differences in how payers cover multiple sclerosis (MS) drugs and can thus affect patients’ access to them.
To examine how the largest private payers cover MS drugs relative to their corresponding FDA approvals and to the evidence that payers report reviewing when formulating their policies.
We identified coverage policies for disease-modifying MS drugs issued by the 10 largest private payers that make their policies publicly accessible. We categorized each policy relative to the drug’s corresponding FDA approval as consistent, more restrictive, less restrictive, or “mixed,” ie, more restrictive than the approval in 1 way, but less restrictive in another. We then categorized the evidence that the payers reported reviewing in their policies into 6 categories: randomized controlled trials (RCTs); other clinical studies (eg, non-RCTs or observational studies); clinical reviews; health technology assessments; clinical guidelines; or cost-effectiveness analyses.
Forty-six percent of coverage policies were more restrictive than the corresponding FDA approval, 38% consistent, 12% less restrictive, and 3% mixed. The payers reported reviewing an average of 1.1 RCTs, 0.4 technology assessments, 0.4 other clinical studies, 1.3 clinical reviews, and 0.8 clinical guidelines per policy. Only 1 payer reported reviewing cost-effectiveness analyses. Payers reported reviewing varying numbers of studies and reviewing differing study types in their coverage policies.
We found variation in how the included payers cover MS drugs and in the evidence that they report reviewing in their coverage policies.