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Variation in the Coverage of Disease-Modifying Multiple Sclerosis Drugs Among US Payers

An examination of payer coverage for multiple sclerosis drugs shows variation in how these drugs are covered and in the evidence that payers review to make these decisions.
Published Online: Sep 21,2017
James D. Chambers, PhD; Jordan E. Anderson, BA; Colby L. Wilkinson, BA; and Pallavi Rane, PhD

Background: 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.

Objectives: 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.

Methods: 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.

Results: 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.

Conclusions: We found variation in how the included payers cover MS drugs and in the evidence that they report reviewing in their coverage policies.

                                                                                         Am J Pharm Benefits. 2017;9(5):155-159

Compared with healthcare systems in other developed countries, the healthcare system in the United States is notably fragmented, with multiple decision makers at the national and local levels.1-3 This fragmentation is apparent in the insurance market, which consists of multiple public payers (including Medicaid, Medicare, the Children’s Health Insurance Program, and the Veterans Health Administration) and private payers. As a consequence, multiple sclerosis (MS) patients across the United States receive their prescription drug insurance coverage from a variety of healthcare payers. Because payers develop their own coverage criteria to guide how their enrolled beneficiaries use drugs and biologics, different patients receiving drug coverage from different payers may have differing access to MS drugs.

We have examined how US payers cover medical technologies in a number of studies. In 1 study, we found variation in how payers cover a variety of interventions, including medications, medical devices, surgeries, and diagnostic imaging and tests.4 In another study, we found variation in how private payers cover rheumatoid arthritis treatments and in the evidence that they reported reviewing in their coverage policies.5 In a separate study, we found inconsistencies in how the largest private payers and Medicare cover medical devices.6 Other researchers have also found variation in how payers cover medical technologies, notably in regard to personalized medicine technologies.7,8
The current study builds on this body of research by examining how the largest US-based private payers cover MS drugs. Our study had 2 objectives. First, we compared how the largest private payers covered disease-modifying drugs relative to their FDA approval. Second, we examined the evidence base that the payers reported reviewing when formulating their coverage policy.


We identified the largest US private payers in terms of market share as reported by the National Association of Insurance Commissioners.9 We then searched each payer’s website to determine whether the payer made its coverage policies publicly accessible. We included the 10 largest payers that make their coverage policies publicly accessible. We excluded Kaiser Permanente and the WellCare Group because they do not publish the required coverage information. We included the following payers in this study (ranked in order of size): UnitedHealthcare, Anthem, Humana, Health Care Service Corporation (HCSC), Aetna, Highmark, Centene, Independence Health Group, Blue Cross Blue Shield of Florida, and Blue Cross Blue Shield of Michigan.

We then searched each included payer’s coverage policies for those pertaining to disease-modifying MS drugs. When a payer had a number of health plan offerings, we included the coverage policies relevant to their commercial line of business. Coverage policies were current as of April 1, 2016. We included coverage policies pertaining to the following disease-modifying MS drugs: dimethyl fumarate, fingolimod, glatiramer acetate, interferon beta-1a (available as 2 branded products, Avonex and Rebif), interferon beta-1b (available as 2 branded products, Betaseron and Extavia), peg-interferon beta-1a, natalizumab, teriflunomide, mitoxantrone, and alemtuzumab. To be consistent with the included payers’ coverage policies, when a drug was associated with 2 different brand names, we considered each brand separately in the analysis.