Do US commercial payers consider HTA and economic evidence when making coverage decisions?

That is the question asked in a new paper by Enright, et al. (2025). The authors use the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database current as of August 2023.  This database contains publicly available specialty pharmacy coverage decisions as issued by 18 large US commercial health plans, which—collectively—cover 200m people (i.e., 70% of US commercially insured lives). The authors used 13,128 coverage decisions in the SPEC database across for 425 drugs, corresponding to 919 drug-indication pairs.

The authors categorized the evidence cited in the coverage policy decisions into 7 categories:

1. Clinical or treatment guidelines,
2. Systematic review and/or meta-analyses,
3. Randomized controlled trials (RCTs)
4. Other clinical studies,
5. Real-world evidence (ie, studies related to the effectiveness of an intervention conducted in a real-world setting),
6. Health technology assessments (HTA),
7. Economic evaluations that otherwise did not qualify as HTAs

Overall, clinical evidence (e.g., clinical guidelines, RCTs) were most frequently cited relative to HTA and other economic evidence.

Nevertheless, most US commercial payers (78.8%) did consider cost effectiveness analysis (CEA) in their evaluation. 

The most commonly cited HTA body evidence came from NICE in the UK (30.7%), ICER in the US (17.7%), and the Canadian Drugs Agency (CDA) (13.4%).

The authors summarize their findings as follows:

Unlike in other countries, where HTA bodies often play a determining role in patient access to drugs, US payers are not bound by such bodies, leaving the role of HTA in US decision-making less defined…Although coverage decisions cited HTAs less frequently than other types of evidence, our findings show that US commercial health plans cite HTA evidence, thus suggesting that they may consider HTA recommendations when formulating coverage.

Why do commercial payers seek out HTA evidence?

HTAs, which are often released around the time of a treatment’s approval, provide timely information for coverage decisions, particularly for complex treatments and orphan drugs, for which initially available evidence may be limited (eg, relying on studies that are not randomized or have small sample sizes)…most HTAs in our sample addressed cost-effectiveness, potentially a key consideration for payers evaluating expensive therapies, such as gene therapies…. Although some health plans may conduct their own technology assessments, others may lack the resources to do so.

You can read the full study here.