A powerful new scorecard from the Institute for Clinical and Economic Review (ICER) assessing 15 of the largest US formularies for barriers to accessing 28 fairly-priced drugs found generally good policies for clinical standards (96% are fair), step therapy (99%), and prescriber restrictions (100%). However, the report found poor policies for cost sharing tiers (77%) that create unfair barriers to accessing medications. Well-designed, fair insurance and PBM (Pharmacy Benefit Manager) policies can encourage patients to access high-value care that is more likely to work for them.
The report’s most encouraging headline is that, when given the draft results, six payers contacted ICER seeking guidance to make their policies more fair. The payers that revised policies to meet fair access standards were Anthem, Blue Cross Blue Shield of Minnesota, Blue Cross Blue Shield of Massachusetts, Elixir PBM, Florida Blue, and United Healthcare.
The report includes detailed performance across the 15 insurers and PBMs. Policy standards include steps required for prior authorization, at least one drug in each class in the lowest cost sharing tier for patients, symptom requirements that are at least as broad as the medication’s FDA label, ensuring high-value treatments are in the best cost sharing tier, ensuring prescribers are either appropriate specialists or consulting with one, and clinically appropriate step therapy.
A less encouraging finding in the report was that many insurer and PBM coverage policies are not transparent or publicly available and so ICER was unable to assess some.
ICER is an independent nonprofit organization that evaluates the effectiveness and cost effectiveness of emerging healthcare treatments. ICER’s reports combine real-world, patient input with the latest clinical and scientific knowledge to calculate evidence-based fair prices for medications and other treatments that reflect the potential to improve patient outcomes for the long term. ICER’s reports, including those from New England CEPAC reports, are used by most major US healthcare payers including Medicare and Medicaid plans, the Veteran’s Administration, and most private payers. ICER is the national leader as a watchdog in controlling drug costs.
ICER hopes this report helps hold insurers and PBMs accountable when their coverage policies are unfair, to ensure payers support patients in choosing the best value care. Thankfully, it appears payers are very interested in improving the fairness of their policies.