Arthritis Foundation Legislative Position Statements

Our Legislative Position Statements

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Biosimilars

The Affordable Care Act creates a regulatory pathway for approving a new generation of biologic medications called "biosimilars," which have the potential to provide safe and effective treatment to people with arthritis at a lower cost than the name-brand biologic medications. We support legislation that provides a pathway for biosimilar substitution.

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Formulary Transparency

Most health insurance plans have a website that allows consumers to compare the costs and benefits of health care coverage, but they don't include specific information for those with arthritis (e.g., cost sharing, prior authorization or step therapy requirements). We support legislation that provides formulary transparency in health insurance plans.

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Narrow Networks

Many people with arthritis who are enrolling in health insurance plans are learning that the availability of doctors, specialists and hospitals through those plans is limited, forcing those who do not have access to necessary medical care through their plans to use costly "out-of-network" providers. We support legislation or regulation that restricts narrow or inadequate networks of providers.

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Out-Of-Pocket Costs

High cost sharing is a barrier to medication access for patients with chronic, disabling and life-threatening conditions. Because many people with arthritis also suffer from other chronic diseases, monthly medication costs can include several kinds of medications, which are often charged at specialty tier costs. We support legislation that limits out-of-pocket costs.

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Prior Authorization

Many insurance companies require a lengthy prior authorization process before dispensing specialty drugs. Each insurance plan has its own prior authorization process for forms, protocols and approval procedures, which often cause unnecessary delays and restrict access to essential patient care. We support legislation to standardize prior authorization protocols and streamline access to vital medications.

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Step Therapy/Fail First

More and more insurers are utilizing step therapy or fail first policies that require patients to try and fail one or more formulary-covered medications before providing coverage for the originally-prescribed non-formulary or non-preferred medication. We support legislation that puts limits on step therapy/fail first protocols.

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Negative Health Insurance Plan Changes

When selecting a health insurance plan, many people with chronic conditions make their decision after carefully weighing a complex variety of factors, including plan cost, medication formulary costs, cost sharing, the availability of specialists and the choice of hospitals. Sometimes, insurance companies change the available benefits of a policy during a contract year, negatively impacting the insured.

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Accurate Provider Network Directories

People with arthritis have very specialized care needs and select insurance plans based on access to doctors who are specialists in practice areas such as rheumatology. Frequently, the selection of an insurance plan comes about because of information contained in directories provided by insurers. We support legislation that provides accurate and reliable information about insurance benefits in provider directories.

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Health Benefit Claim Denial and Appeals Process Disclosures

It is not unusual for an insurer to deny coverage for a medication or a treatment. When an adverse benefit determination or denial is made, it is imperative that the insured know the specific reason for the denial so that they may consult with their physician to evaluate the appropriateness of the decision. We support legislation that provides clear disclosure of the process for appealing insurance coverage denials.