ICER’s 4th annual report finds progress in fair access to prescription drugs
Over the last four years, barriers facing patients getting access to cost effective drugs in commercial plans and the Veteran’s Administration have gotten better, according to ICER’s fourth annual Barriers to Fair Access report. The authors compare plan policies, including cost sharing, clinical eligibility, step therapy and provider restrictions, to independent standards for fair access to prescription drugs that are judged to be a good value. This new report includes real-world cost-sharing and prior authorization data. In general, access policies comply with fair standards.
Drugs tested in this report for fair access across plans include Mounjaro for type 2 diabetes: Wegovy, Saxenda, Qsymia, and Contrave for obesity management; Radicava ORS for amyotrophic lateral sclerosis; Cosela for chemotherapy-induced neutropenia; Veozah for vasomotor symptoms of menopause; Zynteglo for beta thalassemia; Roctavian for hemophilia A; and Hemgenix for hemophilia B.
Coverage policy standards include:
1) Cost Sharing to Patients, with a single criterion requiring that fairly-priced drugs or an equivalent option be placed on the lowest relevant tier of the formulary. Across payer cost sharing policies, 81% were judged to be reasonably priced.
2) Clinical Eligibility, with criteria requiring that coverage for fairly-priced drugs not be narrowed from the FDA label. Across payer clinical eligibility policies, 96% were judged to be fair.
3) Step Therapy Policies, requiring that each step meet standards for clinical appropriateness without a risk for irremediable harm to patients, and that there are no more than three steps to access a drug. Across payer step therapy policies, 100% were judged to be fair.
4) Provider Qualification Restrictions, where fair access requires that there be specific risk for misuse that merits restrictions to specialized prescribers. Also, across provider qualification restrictions policies, 100% were judged to be reasonable.