Tension between two desired goals of ensuring that 1) insurance maximizes personal choice so that patients and clinicians can use healthcare services as they see best to save lives and to improve quality of life; and 2) healthcare is made affordable and resources are managed fairly within the budget constraints, lies at the heart of all health insurance programs. Nowhere is this tension more fiercely debated today than in the area of health benefit design and coverage policy for pharmaceuticals. The question of how to determine whether insurance coverage is providing ‘fair access to a drug’ is infrequently examined.
In this White Paper, published ahead of print in our partner journal, the Journal of Comparative Effectiveness Research, authors affiliated with the Office of Health Economics (London, UK) and the Institute for Clinical and Economic Review (MA, USA) set out ethical goals and design criteria to determine whether insurance coverage is providing fair access to a drug in three areas: cost sharing, clinical eligibility criteria, and step therapy and required switching.
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