January 16, 2020
When a new medication comes on the market, two questions are commonly asked: Is it cost-effective and valuable for our members? How does Premera decide if it will be on our preferred drug list?
The Institute for Clinical and Economic Review (ICER) — a growing not-for-profit organization that evaluates medications, and their cost-effectiveness and value — helps us answer these questions. ICER is an important part of Premera’s business and helps us make healthcare decisions that have a high impact on our members.
ICER membership
Health organizations, insurers, and drug manufacturers are all members of ICER. “Premera became a member in 2015 and had been using a value framework like theirs since 2014,” said John Watkins, senior clinical pharmacist. “Now, we have a relationship that’s built on trust, shared data and analytics, and the common goal of slowing the increase in the cost of care.”
How we work with ICER
With the skyrocketing cost of drugs, ICER’s data can help us determine what medications are the best value for our members. “As a watchdog on drug pricing, ICER provides data on drugs’ cost-effectiveness to better safeguard our members,” Watkins said.
ICER’s reports are used to:
- Assess the value of drugs during Pharmacy and Therapeutics (P&T) reviews
- Obtain information that Premera is unable to get, by using internal resources
- Debate the value of a drug with internal and external stakeholders
- Save the company money. ICER reports help Premera bring an estimated savings between $10,000 and $35,000 per quarterly P&T meeting.
Recently, Vascepa, a new medication to treat high levels of triglycerides (a kind of lipid), came on the market. The ICER review documented it reduces heart attacks and other cardiovascular events in high-risk patients. “ICER’s cost-effectiveness analysis showed that Vascepa has high value, so Premera made it a formulary preferred drug. We wouldn’t have reached this decision without the ICER report,” Watkins said. “The report helps identify patients for whom it would be high value, so we can tailor our prior authorization criteria to cover the drug only for those members.”
Manufacturers lobby Congress and state legislators to restrict our ability to effectively manage expensive drugs. ICER’s annual health policy summit in early December led to a white paper that sets standards for prior authorization and other utilization management criteria. The white paper states what types of restrictions ICER considers ethically appropriate and how they should be implemented. This will help counter the lobbying efforts of pharma companies and make healthcare more affordable.