Can I Access and Afford the Care I Need?  

Prior Authorization

What is prior authorization?   

Prior authorization requires providers to obtain approval from a health insurance plan before certain treatments are covered.   

Why it matters for people with arthritis   

Prior authorization requirements can delay access to prescribed care, interrupt treatment plans and create uncertainty and stress for people living with arthritis. 

What the Arthritis Foundation supports   

• Timely and transparent approval processes 
• Continuity of care protections 
• Policies that reduce unnecessary administrative burden 

Step Therapy

What is step therapy?   

Step therapy requires patients to try certain medications before their insurance will pay for the treatment originally prescribed by their doctor.   

Why it matters for people with arthritis   

Delays in receiving the prescribed treatment can lead to worsening symptoms, joint damage, more pain and avoidable disruption in a patient’s life.   

 What the Arthritis Foundation supports   

• Processes for timely exceptions processes   
• Continuity of care protections  
• Policies that reduce or eliminate unnecessary treatment delays  

Copay Accumulators  

What are accumulator adjustment programs?   

Health insurance policies that do not count manufacturer copay assistance toward a patient’s deductible or out-of-pocket maximum.   

Why it matters for people with arthritis   

Patients — believing they have met their deductible or annual out-of-pocket limit — may face unexpected costs once copay assistance runs out.   

What the Arthritis Foundation supports   

Policies that ensure copay assistance counts toward patient cost-sharing.  

• Transparency in health insurance benefit design  
• Protections against unexpected cost burdens   

PBM Reform 

What are pharmacy benefit managers (PBMs)? 

PBMs help manage prescription drug benefits for health insurance plans and employers. 

Why it matters for people with arthritis 

PBM practices can affect medication affordability, what medications are available and how much they cost, and patient access to treatment. 

What the Arthritis Foundation supports 

• Greater transparency across the prescription drug supply chain 
• Policies that improve patient access to treatments 
• Efforts to reduce unnecessary cost barriers for patients 

Out-of-Pocket Costs

 What are out-of-pocket costs?   

These include deductibles, copayments and coinsurance that individuals must pay for healthcare services and medications.   

Why it matters for people with arthritis   

High out-of-pocket costs can limit access to needed treatment, create financial strain and make it harder for people to stay on medications.  

What the Arthritis Foundation supports   

• Policies that reduce prescription drug costs   
• Greater price transparency   
• Protections that promote affordability 

Insurance Plan Transparency

What is the issue?   

Health plans may change their lists of covered medications (known as formularies), coverage rules or approval requirements (known as utilization management rules) during the health plan year. These changes are not always clearly communicated to patients.   

Why it matters for people with arthritis   

Unexpected insurance changes can disrupt stable treatment plans and make it harder for patients to know what care is covered and what they will owe.   

What the Arthritis Foundation supports   

• Clear communication about coverage policies   
• Protections against disruptive mid-year formulary or other changes   
• Transparency in benefit design (pdf)

Stable & Fair Health Insurance Markets 

 What is market stabilization?   

Market stabilization policies help maintain affordable and predictable insurance markets.   

Why it matters for people with arthritis   

Stable insurance markets help people keep coverage, avoid sudden cost increases and maintain access to treatment over time.   

 What the Arthritis Foundation supports   

• Policies that strengthen insurance market stability   
• Consumer protections that promote continuous coverage   

Surprise Medical Billing 

What is surprise billing?   

Surprise billing occurs when patients receive unexpected charges from out-of-network providers, often during emergencies or at in-network facilities.   

Why it matters for people with arthritis   

Unexpected medical bills can create financial hardship.   

What the Arthritis Foundation supports   

• Protections that prevent surprise medical bills   
• Clear billing practices  
• Fair dispute resolution processes