TABLE 3.
Frequency With Which Plans Impose Coverage Restrictions in Medical and Pharmacy Coverage Policies
| Medical policies, n (%) | Pharmacy policies, n (%) | Total number of medical-pharmacy policy pairs | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No restriction | Any restriction(s)a | Prescriber requirement | Patient subgroup restriction | Step therapy protocol | Not covered | No restriction | Any restriction(s)a | Prescriber requirement | Patient subgroup restriction | Step therapy protocol | Not covered | ||
| Health plan | |||||||||||||
| Plan 1 | 46 (69) | 14 (21) | 1 (2) | 2 (3) | 13 (19) | 7 (10) | 46 (69) | 14 (21) | 1 (2) | 2 (3) | 13 (19) | 7 (10) | 67 |
| Plan 2 | 362 (59) | 249 (41) | 5 (.8) | 64 (10) | 209 (34) | 2 (.3) | 350 (57) | 261 (43) | 5 (.8) | 64 (10) | 222 (36) | 2 (.3) | 613 |
| Plan 3 | 204 (50) | 202 (49) | 1 (.2) | 117 (28) | 101 (25) | 4 (1) | 204 (50) | 202 (49) | 1 (.2) | 116 (28) | 102 (25) | 4 (1) | 410 |
| Plan 4 | 7 (28) | 10 (40) | 10 (40) | 0 | 5 (20) | 8 (32) | 8 (32) | 10 (40) | 10 (40) | 0 | 6 (24) | 7 (28) | 25 |
| Plan 5 | 173 (56) | 123 (40) | 3 (1) | 23 (8) | 110 (36) | 12 (4) | 183 (59) | 115 (37) | 3 (1) | 19 (6) | 104 (34) | 10 (3) | 308 |
| Plan 6 | 35 (34) | 61 (59) | 43 (41) | 15 (14) | 34 (33) | 8 (8) | 36 (35) | 60 (58) | 22 (21) | 22 (21) | 32 (31) | 8 (8) | 104 |
| Plan 7 | 34 (44) | 32 (42) | 0 | 8 (10) | 28 (36) | 11 (14) | 35 (46) | 34 (44) | 18 (23) | 9 (12) | 24 (31) | 8 (10) | 77 |
| Plan 8 | 4 (27) | 11 (73) | 0 | 2 (13) | 11 (73) | 0 | 2 (13) | 13 (87) | 11 (73) | 2 (13) | 9 (60) | 0 | 15 |
| Cancer indication | |||||||||||||
| Yes | 447 (74) | 152 (25) | 3 (.5) | 78 (13) | 72 (12) | 2 (.3) | 455 (75) | 144 (24) | 2 (.3) | 80 (13) | 65 (11) | 2 (.3) | 601 |
| No | 418 (41) | 550 (54) | 60 (6) | 153 (15) | 439 (43) | 50 (5) | 409 (40) | 565 (56) | 69 (7) | 154 (15) | 447 (44) | 44 (4) | 1,018 |
| Orphan drug designation | |||||||||||||
| Yes | 416 (64) | 230 (36) | 28 (4) | 124 (19) | 120 (19) | 2 (.3) | 421 (65) | 225 (35) | 31 (5) | 127 (20) | 112 (17) | 2 (.3) | 648 |
| No | 449 (46) | 472 (49) | 35 (4) | 107 (11) | 391 (40) | 50 (5) | 443 (46) | 484 (50) | 40 (4) | 107 (11) | 400 (41) | 44 (5) | 971 |
| Total | 865 (53) | 702 (43) | 63 (4) | 231 (14) | 511 (32) | 52 (3) | 864 (53) | 709 (44) | 71 (4) | 234 (14) | 512 (32) | 46 (3) | 1,619 |
aPolicies may have more than 1 type of restriction, eg, prescriber requirement, patient subgroup restriction, and/or step therapy protocol.