Arthritis Foundation Legislative Position Statements

Arthritis Foundation Position Statement on Prior Authorization

Issue

Before specialty drugs are dispensed, many insurance companies require a complex process called prior authorization. Each insurance plan has its own system of forms, protocols and approval procedures, which may vary based on the medication or therapy under review. As a result, prior authorization typically causes lengthy delays in treatment, thereby restricting a person's access to vital care.

Background

Physicians must fill out a prior authorization form whenever they prescribe a specialty medication or treatment that is restricted or not covered under the insurer's formulary, placing an unnecessary burden on patients, pharmacies and doctors. In the current system, each insurer uses its own unique and distinct form, and physicians may have to spend many hours familiarizing themselves with and completing dozens of forms of varying lengths and complexities.

Under this system, after physicians process these forms, they are often required to wait days before receiving notification of an approval, denial or request for additional information.

Arthritis Foundation Position

The Arthritis Foundation supports legislation that would standardize prior authorization protocols and streamline access to vital medications and treatments for people with arthritis. Legislation should:

  • Establish a single, standardized form for physicians to submit prior authorization requests.
  • Establish electronic systems for the submission of prior authorization requests.
  • Require prior authorization requests to be completed by insurers within 48 hours of submission or receive automatic approval.
  • Once approved, permit authorizations to remain in place for up to 12 months for people with chronic conditions, such as rheumatoid arthritis (RA).
  • If a prior authorization request is denied, the member must be given clear instructions on how to file an appeal, the information required and deadlines.
  • Provide a process for expedited appeals, especially for urgent care services.

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