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Are health insurers providing fair access?


How well did payers provide “fair” access policies? Based on an recent ICER report titled “Assessment of Barriers to Fair Access“, the headline figures seem pretty good:

Overall rates of concordance with ICER’s criteria were 70% for cost sharing of fairly-priced drugs, 96% for clinical eligibility criteria, 98% for step therapy, and 100% for provider restrictions

It seems that this is fair access at first glance. But, digging deeper, you will see that patients still face significant hurdles.

The table below shows that although 70% of drugs received fair accessibility, this is only based on the 84 actual drugs covered by insurance. However, 75% (758 of 342) drugs were not covered by insurance. Cost sharing was therefore 100%. If we include both covered and non-covered drugs in the analysis, then cost sharing would be considered fair based on ICER’s criteria only 17.4% (n=59 out of 352) of the time.

Payers were more likely follow ICER rules in relation to provider restrictions, clinical eligibility, and limitations on steps therapy. Some of these fairness criteria are however very low. For example, ICER states…

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