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February 8, 2026Journal of Managed Care & Specialty Pharmacy0 citations

Use of clinical outcome assessments in specialty drug coverage policies

JRJulia A. RuckerJPJIAT LING POONFLFariel C. A. LaMountain

Key Points

  • The aim is to evaluate how clinical outcome assessments are utilized in specialty drug coverage policies and their impact on patient access to treatment.
  • Analyzed inclusion of clinical outcome assessments across different health plans.
  • Identified and categorized types of clinical outcome assessments used, focusing on ClinROs and PROs.
  • Compared the frequency of PRO inclusion among various plans to assess consistency in policies.
  • Most plans used clinical outcome assessments primarily to restrict access to treatments.
  • ClinROs were the most frequently employed type of assessment, placing providers at the forefront of treatment access decisions.
  • Patient-reported outcomes were less commonly included, indicating a potential gap in incorporating patient perspectives.

Abstract

COA inclusion varied across plans, with most using them to limit access. ClinROs were the most frequently used COA type, underscoring the pivotal role of providers on behalf of patients and health plans in shaping treatment access decisions. Plans used PROs relatively infrequently, with some including PROs in their policies more than others, suggesting a missed opportunity to consistently incorporate patients' voices to complement the assessment of treatment outcomes when determining coverage. Future research should explore the rationale behind COA use and its implications for treatment access.

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Cite This Study

Rucker et al. (2026) studied this question.

synapsesocial.com/papers/698827570fc35cd7a884603dhttps://doi.org/10.18553/jmcp.2026.32.2.143
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