TOPLINE:

Drug pricing, competition, and characteristics were associated with health plan restrictions, but rebates were not. Higher net prices of the drugs were associated with an increased likelihood of restrictions.

METHODOLOGY:

• Researchers conducted a cross-sectional study to assess whether drug prices and rebates affected the frequency of coverage restrictions.
• They analyzed 161 drugs from the Tufts Medical Center Specialty Drug Evidence and Coverage database and the SSR Health US Brand Rx Net Pricing Tool, using data from January to December 2023.
• Overall, 6688 coverage decisions (drug-indication-plan triplets) across 195 indications and 422 US FDA-approved drug-indication pairs were examined.
• Coverage decisions were categorized as unrestricted (the full FDA-approved population) or restricted, which require specific clinical criteria or step therapy.
• Non-Medicaid net prices (the manufacturer’s revenue after discounts and rebates) for each drug were calculated, and rebate sizes were estimated using SSR annual cost data.

TAKEAWAY:

• The median annualized net drug price was $48,700, and the median rebate was $29,400, with a median discount from the list price of 27.8%.
• Overall, 46.3% of coverage decisions included at least one restriction.
• Drugs with higher ($166,437 or more) vs lower (less than $20,784) net prices were initially less likely to face restrictions. However, after controlling for confounding factors, higher net prices were associated with higher odds of restrictions (odds ratio, 2.28; P = .03).
• Oncology drugs and FDA-designated second-line or later drugs were less likely to be restricted, whereas drugs in highly competitive classes were more likely to face restrictions. Rebate size was not linked to coverage restrictions.

IN PRACTICE:

“Given the importance of this topic and our contrasting findings across modeling approaches, the association between rebates and access restrictions should be explored further,” the authors of the study wrote.

SOURCE:

The study was led by Molly T. Beinfeld, MPH, Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston. It was published online on February 06, 2026, as a research letter in JAMA Network Open.

LIMITATIONS:

The study’s findings may not be applicable to all drugs or types of plans. The SSR relied on disclosures from public manufacturers, excluding drugs from private manufacturers, and may have potential inaccuracies for low-sales drugs. The definition of restrictiveness used in the study may not have captured all access strategies.

DISCLOSURES:

The study was funded by a grant from argenx, Inc to Tufts Medical Center. No relevant conflicts of interest were reported by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.