This Viewpoint examines variations in US commercial health plan coverage restrictions for cell and gene therapies.

INTRODUCTION Older adults with dementia incur considerable out-of-pocket (OOP) health care expenses, but it is unclear how their financial burden differs by dementia stage. METHODS We identified 2...

Current methodological guidelines for value/health technology assessment (V/HTA) and cost-effectiveness analysis describe traditional approaches not originally created to be patient centered. The obje...

The Centers for Medicare and Medicaid Services (CMS) can now negotiate the prices of a set of drugs that represent significant Medicare expenditures. The long-term success of negotiations will depend ...

AbstractIntroduction. Prescription drug list prices, often cited in policy discussions, do not account for rebates negotiated between manufacturers and pay

Vanderbilt recently hosted 11 international fellows to provide training to help them address public health issues in their home countries.

Overview The Tufts University Graduate School of Biomedical Sciences (GSBS) Clinical and Translational Science (CTS) Graduate Program is delighted to offer an accredited Certificate Program in Health ...

Utilization management criteria influence patients’ access to specialty drugs, yet the processes used by health plans to establish these criteria are not well understood. This study examined the alignment between clinical practice guidelines and plans’ utilization management criteria. Using the Tufts Medicine Specialty Drug Evidence and Coverage Database (December 2023), we reviewed US-based guidelines for 389 drug-indication pairs, excluding oncology and biosimilar treatments. We categorized guidelines as recommending or not recommending utilization management, based on alignment with each drug’s Food and Drug Administration label—specifically, line of therapy and clinical requirements (for example, disease severity). We analyzed 5,699 coverage policies from eighteen large commercial health plans. When guidelines recommended utilization management, 67 percent of plans’ coverage decisions aligned with the recommendation; when guidelines did not recommend utilization management, only 37 percent of decisions were consistent. Most plans imposed utilization management criteria (61 percent of all decisions), and plans were more likely to be consistent with guideline recommendations when utilization management was recommended, indicating a weak alignment with guideline recommendations.

Combination therapies are a mainstay in cancer treatment, but reimbursement access can be limited, owing to complexities around value assessment and pricing,...

Background The introduction of new Alzheimer's disease (AD) treatments necessitates updated health utilities for economic evaluations. Objective Measure h...