ICER puts spotlight on health insurers

ICER puts the Spotlight on Health Insurers


New Annual Report Will Assess Coverage Policies and Critique Fairness of Access 


Over recent years, the US has witnessed an ongoing national debate over fair drug pricing and despite great attention placed on the methods used to determine drug prices there is little focus on whether insurance coverage is providing fair access to such drugs. 

As a result, the Institute of Clinical or Economic Review (ICER) recently outlined its plans to annually assess Barriers to Fair Access within prescription drug coverage policies of major US payers with an aim to support transparent decision making over patient access to prescription drugs across some of the USA’s largest insurance providers. 

A Recent Outlook: 

ICER builds its new plans on it’s 2020 White Paper which analysed insurance coverage policies and presented a recommended set of criteria to support discussion regarding “fair” patient access to prescription drugs. 

ICER’s next step is to apply these criteria to drugs identified as being cost-effective by the Insitition between 2015-2020. In doing so, coverage policies of 28 drugs across the largest formularies of the top 15 commercial payers in the US will be evaluated in terms of cost sharing, clinical eligibility criteria, prior authorization processes and step therapy protocols, with the first report of the Barriers to Fair Access Assessment scheduled to be released in October 2021.  

As stated within the Assessment Protocol which was released in May 2021 – ‘The overall objective of the assessment is to test whether the fair access criteria can help bring greater transparency to the public debates about fair insurance coverage for drugs and, in addition, promote the positive linkage of fair pricing with fair access that will advance the best interests of patients and the health system.’   

To help achieve such ambitious targets, ICER will utilise a “working group” consisting of several patient advocates and providers. The aim of this group is to advise the Institute on the application of the fair access criteria and the provide insight into the patient experience surrounding prescription drug coverage and access. Notably, only one health insurer and one PBM member is expected to sit on the panel demonstrating the strong relationship ICER is continuing to build with patient groups over payers.  

Expected impact: 

The decision to begin scrutinising payer policies which have the ability to limit patient access is a signal of ICER’s independence and willingness to explore not only manufacturers but also payers themselves. However the overall goal of helping improve patient access in the US will likely be received well by the medical and political community who have continuously criticised US payers and manufacturers for their drug pricing and access criteria. 

As this work continues, it will be interesting to see if there will be any changes in how ICER is utilised within the US pharmaceuitcal space and whether the Barrier’s of Fair Access reports are a forerunner for additional examinations of US payer policies.  

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