ICER Publishes Protocol for First Annual Assessment of Drug Coverage Policies That Present Barriers to Fair Access

— ICER’s analysis, based on MMIT’s market access Analytics solution, will evaluate how 15 of the largest US payers provide coverage for 28 cost-effective prescription drugs —

— The goal of the project is to spark further dialogue and action in the best interest of patients by providing an independent analysis of whether or not major insurers are providing appropriate access for drugs that have been responsibly priced —

BOSTON, May 25, 2021 – The Institute for Clinical and Economic Review (ICER) today posted a Protocol outlining how we will conduct our first annual assessment into 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, US payers, 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.

Building on the criteria discussed within that paper, ICER convened a multi-stakeholder working group — comprising more patient community leaders than all other stakeholders combined — to advise ICER as we undertake this new annual initiative to assess Barriers to Fair Access within the prescription drug coverage policies of major US payers. 

In the first iteration of this annual assessment, ICER will use MMIT’s market access Analytics solution to evaluate the coverage policies of 15 of the largest commercial payers in the US. For each formulary, ICER will examine tiering, step therapy requirements, and elements of the prior authorization criteria for 28 specific drugs – all of which ICER has previously found to be priced fairly at a cost-effective level – to determine if coverage policies are in concordance with criteria for fair patient access.

ICER anticipates publishing its first annual assessment of Barriers to Fair Access on October 20, 2021. The complete timeline for this initiative is available here.

About ICER

The Institute for Clinical and Economic Review (ICER) is an independent non-profit research institute that produces reports analyzing the evidence on the effectiveness and value of drugs and other medical services. ICER’s reports include evidence-based calculations of prices for new drugs that accurately reflect the degree of improvement expected in long-term patient outcomes, while also highlighting price levels that might contribute to unaffordable short-term cost growth for the overall health care system.