(M5) Current Patterns, Future Shifts, and Best Practices in U.S. Specialty Drug Coverage

The Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database contains information on 18 of the largest commercial (employer-sponsored) health plans’ specialty drug coverage policies, covering about 70% of the U.S. commercial payer market. Using this resource, faculty will demonstrate variation in the use of utilization management (UM) tools among health plans and will illustrate an overarching trend toward increased adoption of UM tools within specialty therapy policies. Through case studies, attendees will understand the variability in evidence cited by health care decision-makers (HCDMs) in their coverage policies, as well as differences between therapeutic areas, such as orphan versus non-orphan diseases. These trends will be thoroughly explored, and their underlying causes will be investigated during this session. Faculty will further analyze the implications and offer insights into what can be expected for health plan coverage of specialty therapies (including high-investment medications like gene therapies) in the future.