DO PAYERS COVER CANCER AND NON-CANCER DRUGS DIFFERENTLY?

OBJECTIVES: Evidence suggests that health technology assessment agencies across the globe may use different assessment criteria for cancer and non-cancer drugs. Our objective was to compare coverage decisions for cancer and non-cancer drugs issued by US private health care payers to determine if cancer drugs are subject to fewer coverage restrictions. METHODS: We identified coverage decisions for cancer and non-cancer drugs from the Tufts Medical Center Coverage Determination database which includes 3,432 coverage decisions issued by 17 of the largest commercial payers (in terms of covered lives). We compared each payer's coverage decision for each drug against the drug's corresponding FDA label. We categorized each coverage decision as: (a) more restrictive than the FDA label (the payer placed conditions on coverage beyond the FDA label); (b) consistent with the FDA label; (c) less restrictive than the FDA label (the payer covered the drug for a broader patient population than the FDA label); or (d) mixed (the payer's coverage decision was more restrictive than the FDA approval in one way but was less restrictive in another). We compared the restrictiveness of coverage of cancer and non-cancer drugs using a chi-squared test. RESULTS: The database contains 2,507 coverage decisions for non-cancer drugs, and 925 coverage decisions for cancer drugs. For non-cancer drugs, coverage was more restrictive on 35% (n=877) occasions, consistent on 53% (n=l,324) occasions, less restrictive on 4% (n=109) occasions, and mixed on 2% (n=51) occasions. For cancer drugs, coverage was more restrictive on 5.3% (n=49) occasions, consistent on 70.7% (n=650) occasions, less restrictive on 21.9% (n=201) occasions, and mixed on 1.2% (n=ll) occasions. We found a statistically significant (p