BOSTON, April 12, 2023 – The Institute for Clinical and Economic Review (ICER) today posted a Protocol outlining how we will conduct our third annual assessment of how well major insurers’ prescription drug coverage policies align with a set of fair access standards developed by ICER with expert input from patient advocates, clinician specialty societies, payers, pharmacy benefit managers, and life science companies.
In September 2020, ICER published the white paper: “Cornerstones of ‘Fair’ Drug Coverage: Appropriate Cost-Sharing and Utilization Management Policies for Pharmaceuticals.” This paper analyzes the ethical and practical dimensions of insurance coverage policy, while presenting a corresponding set of criteria that will support a more transparent discussion among all health care stakeholders about whether specific policies are delivering “fair” patient access to prescription drugs. The criteria to be evaluated in this year’s assessment include those related to patient cost sharing, clinical eligibility criteria, step therapy, and provider restrictions. The availability of these policies to prospective health plan enrollees will also be evaluated.
ICER will use the MMIT’s market access Analytics solution to identify the formularies that will be included, and will solicit coverage policies directly from payers, supplementing their responses with information from the MMIT database. For this report, ICER will review multiple formularies offered by the five largest US commercial payers, state health exchange plans in the four geographic regions of the US, and the Department of Veterans Affairs.
For each of the drugs reviewed by ICER in 2021 we will perform analyses of the proportion of selected fair access criteria that are met in these formularies, analyzed across drugs, conditions, and payers. The following drugs in the 2021 ICER assessments are in scope for this initiative: