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Utilization Management Trends in the Commercial Market, 2014–2020

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Summary

The Pharmaceutical Research and Manufacturers of America (PhRMA) commissioned Avalere to examine the prevalence of utilization management (UM) over time in the commercial market, which includes employer-sponsored health plans and the health insurance exchanges.

Health insurance plans use UM to manage spending on prescription drugs, address safety concerns, and promote quality care. Many factors influence drug coverage and the use of UM, including drugs’ clinical profiles, therapeutic competition, costs, and rebate dynamics. As healthcare costs continue to increase across the spectrum of covered services, insurers may increasingly manage access to new drugs as a strategy to reduce spending.

PhRMA commissioned Avalere to examine the prevalence of UM over time in the commercial market, which includes employer-sponsored health plans and the health insurance exchanges. For the purposes of this study, drugs subject to UM are those covered on a plan’s formulary with prior authorization (PA) or step therapy (ST) requirements.

The white paper resulting from this study focuses on coverage policies of single-source brand drugs for 12 therapeutic areas (TAs) from 2014 to 2020. This sample represents Food & Drug Administration-approved brand medicines produced by only 1 manufacturer (single source) on the market during the study period. More information on the method is included in the Detailed Methodology section of the white paper.

Avalere’s findings provide a view into the evolution of how insurers approach coverage for single-source brand drugs. Because of this focus, the list of drugs included each year changes as new drugs enter the market and some brands lose their single-source status when generic equivalents became available. Therefore, findings should not be construed as an analysis of coverage policies for a specific static list of drugs over time.

Therapeutic Areas Studied

Cancer

  • Chronic Myeloid Leukemia (CML)
  • Multiple Myeloma (MM)

Mental Health

  • Atypical Antipsychotics (AA)
  • Depression Autoimmune Disorders
  • Multiple Sclerosis (MS)
  • Psoriasis
  • Rheumatoid Arthritis (RA)

Other Chronic Conditions

  • Asthma/Allergy Corticosteroids (AAC)
  • Cardiovascular (CV) Agents
  • Diabetes Glucagon-like Peptide-1 (GLP1) Agonist
  • Diabetes Sodium-glucose Cotransporter-2 (SGLT2) Inhibitor
  • HIV

Highlights

  • From 2014 to 2020, the use of UM in the commercial market increased for all studied TAs.
  • The share of medicines covered without UM (i.e., open access) decreased for all included TAs, except depression and psoriasis, over the study period.
  • In 2020, PA was used more often for multiple myeloma, chronic myeloid leukemia, and autoimmune disorders than for the other TAs studied.
  • ST was used most frequently for medicines to treat rheumatoid arthritis and psoriasis.
  • Within the commercial market, exchange plans impose UM more often than employer plans.

Many factors influence drug coverage and the use of UM by commercial plans. As healthcare costs continue to increase and more innovative and specialized therapies enter the market, insurers and employer plan sponsors may be pursuing more aggressive management of access to new drugs as a strategy to manage spending. As a result, providers treating patients with serious chronic conditions may experience increased administrative burdens associated with UM processes, and patients may experience delays in accessing prescribed medicines.

For Avalere’s complete analysis of utilization management trends, download the full white paper.

Funding for this research was provided by PhRMA. Avalere Health retained full editorial control.

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