— ICER will evaluate whether the 15 largest US commercial payers, the 2 largest state health exchange plans, and the Department of Veterans Affairs have formularies and procedures that provide appropriate access to the prescription drugs reviewed by ICER in 2020 —

Coverage policy data will be accessed through MMIT’s market access Analytics solution, supplemented by input directly from payer organizations —

BOSTON, May 23, 2022 – The Institute for Clinical and Economic Review (ICER) today posted a Protocol outlining how we will conduct our second 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, 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.

Building on the criteria discussed within that paper, ICER convened a multi-stakeholder working group — consisting of representatives from leading patient advocacy groups, clinical societies, pharmacy benefit managers, and the life sciences industry— to advise ICER on this annual initiative to assess Barriers to Fair Access within the prescription drug coverage policies of major US payers. 

ICER will continue to use MMIT’s market access Analytics solution to evaluate the coverage policies of the 15 largest commercial payers in the US, expanded for the 2022 report to include the Department of Veterans Affairs and the two largest state ACA exchange health plans.
For each of the drugs reviewed by ICER in 2020 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 drugs in the 2020 ICER assessments on cystic fibrosis, hemophilia A, migraine, sickle cell disease, and ulcerative colitis are in scope for this initiative.

ICER anticipates publishing its assessment of Barriers to Fair Access on January 17, 2023. 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.