— During ICER’s assessment, five payers revised policies for 11 drugs in ways that bring coverage into concordance with fair access criteria, demonstrating that assessment and greater transparency may lead to positive change —
BOSTON, January 17, 2023 — The Institute for Clinical and Economic Review (ICER) today published its second annual “Barriers to Fair Access” assessment of prescription drug coverage policies (Report | Supplemental Materials). While many key elements of fair access were not able to be assessed, the analysis found that major payer coverage policies for 19 drugs demonstrated high concordance with many fair access criteria related to cost sharing, clinical eligibility, step therapy, and provider restrictions. Further, the report’s findings suggest that major improvements are needed in the transparency of coverage policy information for consumers, and in reducing the complexity of the prior authorization process for both clinicians and patients. And finally, because five payers chose to revise policies for 11 drugs initially judged to be out of line with fair access criteria, it is clear that greater transparency into payer coverage policies can lead to positive change for patients.
“Payers, pharmacy benefit managers, and drug makers all have a role to play in ensuring fair pricing and fair access to prescription drugs; while much attention is paid to the prices chosen by drug makers, this second annual Barriers to Fair Access report shows that the payer community has a critical role to play in ensuring access,” stated Sarah K. Emond, MPP, Executive Vice President and Chief Operating Officer at ICER. “While many of the concordance levels for adhering to fair access criteria were high, we know that patients still face significant barriers to access because of policy choices made by payers. Because our annual exercise, which shines a light a small number of payer policies, leads to payers improving the fairness of their coverage policies, we are demonstrating that transparency and analysis can help the system move to what we all want – fair prices, and fair access.”
Using a leading proprietary database of formulary coverage information from MMIT Analytics Market Access Database, the report evaluated the insurance coverage policies of the largest formularies of leading payers against ICER’s fair access criteria for 19 drugs reviewed by ICER in 2020. Payer formularies assessed included the following:
- the 15 largest commercial formularies in the United States;
- The Veterans Health Administration (VHA);
- Formularies of the two largest state ACA exchange health plans.
The assessment found a high level of alignment between coverage policies and fair access criteria across the formularies with the highest number of covered lives of large private payers and the VHA in the United States. Across all relevant payer policies, ICER gave concordance ratings of 70% (59/84) for cost-sharing policies of drugs that ICER found to be reasonably priced, 96% (310/322) for clinical eligibility criteria, 98% (316/322) for step therapy criteria and 100% (322/322) for prescriber restrictions.
In the exploratory transparency analysis for select migraine and ulcerative colitis (UC) drugs aimed at discerning whether prospective plan members can find information about cost-sharing and clinical eligibility, payers were found to provide relatively good transparency into their formularies (16/18 payers met transparency criteria) but only 10/18 payers provided adequate transparency into their clinical coverage policies. In an exploratory analysis for documentation burden which reviewed the number of questions on prior authorization forms, prior authorization policies for UC and migraine drugs had a median number of questions from 25 to 36 and a range of questions from 22 to 71.
One of the most notable results of this effort is the change in coverage policies made by five payers for 11 drugs following receipt of draft results of the assessment. These changes all served to bring coverage into alignment with fair access criteria.
ICER will host a public webinar at 12:00 p.m. ET on January 18, 2023 to discuss the key conclusions and policy implications of this assessment. Webinar presenters will include:
- Sarah Emond, MPP, Executive Vice President and Chief Operating Officer, ICER
- Mary B. Dwight, Senior Vice President and Chief Policy & Advocacy Officer, Cystic Fibrosis Foundation
- Meghan Buzby, Executive Director, Coalition for Headache and Migraine Patients (CHAMP)
If you have any questions about this report or the public webinar, please email firstname.lastname@example.org.
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.