Pharmacy NewsPublished January 27, 2020
A new medicine comes on the market and two commonly asked questions follow: is it cost-effective and valuable for our members? How does Premera Blue Cross decide if a new medicine will become part of our preferred drug list?
The Institute for Clinical and Economic Review (ICER)—a growing not-for-profit organization that evaluates drugs and their cost-effectiveness and value—helps us answer these questions. If you’re not engrained in the pharmacy world, you may not know what ICER is. At Premera, ICER is an important part of our business and helps us make healthcare decisions that have a high impact on our members.
Premera, along with other leading health organizations, insurers, and drug manufacturers, are members of ICER. “Premera was an early adopter of ICER. In 2014, we had developed a value framework similar to theirs in 2009, so it was a natural partnership. And in 2015, we become a member,” John Watkins, senior clinical pharmacist said. “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.”
“As a watchdog on drug pricing, ICER provides data on drugs’ cost-effectiveness so that we can better safeguard our members,” John said. We use ICER’s reports to:
With the skyrocketing cost of drugs, ICER’s data can help us determine what medicines are the best value for our members. Recently, Vascepa, a new drug for people with high levels of triglycerides (a kind of lipid), came on the market. The ICER review documented that 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,” John said. “The report also told us how to 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.
ICER is also helping us set standards for prior authorization and other utilization management (UM) criteria. Manufacturers lobby Congress and state legislators to restrict our ability to effectively manage expensive drugs. These standards will state what types of restrictions ICER considers ethically appropriate and how they should be implemented. This will help Premera continue on our mission to make healthcare better and more affordable.
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