ICER Report: Price Transparency, Prior Authorization Process Need Improvements

Major drug coverage policies were in high concordance with fair access criteria, but further efforts are needed to improve price transparency for consumers and reduce the complexity of the prior authorization process, according to a report by the Institute for Clinical and Economic Review (ICER).¹

The second annual Barriers to Fair Access report assessed major coverage policies for 19 drugs that were involved in ICER evidence reviews in 2020. Using the MMIT Analytics Market Access Database, ICER evaluated the policies of the 15 largest US commercial formularies, the Veterans Health Administration, and the 2 largest state Affordable Care Act exchange health plans.

Per the report, fair access criteria included the following: cost-sharing provisions and tier placement; timeliness of prior authorization protocol development following a drug’s approval; clinical eligibility criteria; step therapy and medication switch requirements; and restrictions on prescriber qualifications.

ICER found most policies were in high concordance with fair access criteria, with rates of:

• 70% (59 out of 84) for cost-sharing policies for reasonably priced drugs;
• 96% (310 out of 322) for clinical eligibility criteria;
• 98% (316 out of 322) for step therapy criteria; and
• 100% (322 out of 322) for prescriber restrictions.²

ICER also investigated whether consumers could find cost-sharing and clinical eligibility information related to drugs for migraine and ulcerative colitis. Most payers (16 out of 18) provided relatively good transparency into their formularies, but only 10 out of 18 payers offered adequate transparency into their coverage policies, according to an ICER press release.

Additionally, ICER recommended further efforts to reduce the complexity of the prior authorization process. The report showed prior authorization forms for these drugs required providers and patients to answer a median 25 to 36 questions, with the number ranging as high as 71.

“Payers, pharmacy benefit managers, and drug makers all have a role to play in ensuring fair pricing and fair access to prescription drugs,” said Sarah K. Emond, MPP, executive vice president and chief operating officer, ICER. “While much attention is paid to the prices chosen by drug makers, this second annual Barriers to Fair Access report shows that the payer community has a critical role to play in ensuring access.”

During the assessment, 5 payers changed policies for 11 drugs to be in better alignment with fair access criteria, prompting ICER to conclude greater transparency into coverage policies “can lead to positive change for patients.”

“While many of the concordance levels for adhering to fair access criteria were high, we know that patients still face significant barriers to access because of policy choices made by payers. Because our annual exercise, which shines a light a small number of payer policies, leads to payers improving the fairness of their coverage policies, we are demonstrating that transparency and analysis can help the system move to what we all want—fair prices, and fair access,” Ms Emond said.

ICER noted the report did not address several other factors which may contribute to fair access barriers such as coverage for off-label prescribing, high-deductible benefit designs, and copayment coupons, among others.

References:

1. Institute for Clinical and Economic Review. Assessment of barriers to fair access final report. January 17, 2023. Accessed January 17, 2023. https://icer.org/wp-content/uploads/2023/01/2022-Barriers-to-Fair-Access-Assessment-Final-Report-011723.pdf
2. ICER publishes second annual assessment of barriers to fair access within US commercial insurance prescription drug coverage. News release. Institute for Clinical and Economic Review; January 17, 2023. Accessed January 17, 2023.