ICER Report Calls for Greater Coverage Policy Transparency

Major payer coverage policies across select categories often met fair access criteria for cost sharing, clinical eligibility, step therapy and provider restrictions, according to the third annual “Barriers to Fair Access” assessment published by the Institute for Clinical and Economic Review (ICER).

The analysis examined coverage policies for 18 drugs across 10 commercial formularies, eight Affordable Care Act exchange plans and the Veterans Health Administration national formulary, representing 42 million enrollees in total. ICER asked the payers for coverage policy information and leveraged the MMIT Analytics Market Access Database for additional information. (MMIT is the parent company of AIS Health, which maintains journalistic independence and did not play a role in producing the report.)

The 18 prescription drugs comprised eight different therapeutic classes. ICER found that 99% of formularies were “concordant” (i.e., aligned) with its clinical eligibility criteria for fair access, 99% were concordant with step therapy criteria and 100% were concordant with prescriber restriction standards. Additionally, ICER found that 62% of policies for the two drugs that it deemed cost-effective — lupus nephritis drug Benlysta (belimumab) and cholesterol-lowering drug Nexlizet (bempedoic acid/ezetimibe) — were concordant with fair access standards regarding cost sharing.

The analysis showed that there were high rates of concordance for clinical eligibility, step therapy and prescriber restrictions regardless of formulary type, size and location. For lupus nephritis treatments, the majority (53%) of formulary policies for Benlysta had cost sharing criteria that did not meet ICER’s fair-access criteria. Four formulary policies for the high cholesterol treatment Nexlizet did not meet the cost-sharing criteria for fair access.

The report also analyzed the transparency of formulary polices for three drugs: cholesterol-lowering drug Nexletol (bempedoic acid), atopic dermatitis medication Rinvoq (upadacitinib) and myasthenia gravis drug Vyvgart (efgartigimod). While cost-sharing and tier information were provided for each drug, researchers found that policies related to copay adjustment programs and continuation of coverage were frequently unavailable or difficult to understand.

This infographic was reprinted from AIS Health’s biweekly publication Radar on Drug Benefits.

© 2024 MMIT
Jinghong Chen

Jinghong Chen Reporter

Jinghong has been producing infographics and data stories on employer-sponsored insurance, public health insurance programs and prescription drug coverage for AIS Health’s Health Plan Weekly and Radar on Drug Benefits since 2018. She also manages AIS Health’s annual executive compensation database for top insurers and Blue Cross and Blue Shield affiliates. Before joining AIS Health, she interned at WBEZ, Al Jazeera English and The New York Times Chinese. She graduated from Missouri School of Journalism with a focus on data journalism and international reporting.

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