OBJECTIVES: Health plans use utilization management (UM) tools to guide their enrollees’ access to specialty drugs. Our objective was to examine how US commercial health plans’ use of UM changed from 2017 through 2021.

METHODS: We used the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database to identify coverage policies for 363 specialty drug-indication pairs (e.g., infliximab for rheumatoid arthritis) issued by 17 large US commercial payers from 2017 through 2021. In SPEC, UM is categorized as: (i) subgroup restrictions, e.g., patients must have symptoms of particular severity, (ii) step therapy protocols, i.e., patients are required to first fail an alternative therapy, (iii) and prescriber requirements, i.e., a particular type of physician must prescribe the drug. We categorized drug-indication pairs with respect to orphan status, ICD 10 category, inclusion in an FDA-expedited approval program, and pediatric indications.

RESULTS: Our sample included 23,977 specialty drug coverage policies over 5 years. From 2017 to 2021, 13 plans used UM more often and four plans used UM less often. Overall, the proportion of policies with no UM declined from 60.6% in 2017 to 48.4% in 2021, while the proportion of policies with multiple UM tools (e.g., a subgroup restriction and a step therapy protocol) increased from 10.2% to 18.3%. Growth in UM was mostly due to plans’ increased use of step therapy and prescriber requirements; plans’ use of subgroup restrictions remained relatively constant. Plans’ use of UM for oncology and orphan drugs, while lower than for non-oncology drugs and non-orphan drugs, increased from 17.3% to 32.7% and 30.8% to 46.9% of policies, respectively.

CONCLUSIONS: US commercial health plans’ use of UM increased from 2017-2021; however, findings varied by payer and across drug attributes. Plans use of step therapy protocols and prescriber requirements became increasing common over the study time period.