Insurance Plan Transparency 

Getting proper arthritis treatment through an insurance provider can be difficult due to prior authorization, cost sharing and step therapy requirements. Find out why insurance plan transparency is so critical to arthritis patients. 

The Issue

  • Most health insurance plans have a website that allows consumers to compare costs and benefits as they shop for health care coverage. However, these websites often lack specific information on issues of importance to people with arthritis, such as cost sharing, prior authorization or step therapy requirements regarding particular medications, and appeal processes.  
  • When adverse benefit determinations, or denials, are made, it is imperative that plan members know the specific reason for denials so they can consult their physician to evaluate the appropriateness of the decisions.  
  • A person who doesn't know they have the right to appeal, or the information necessary to conduct the appeal, may be wrongfully or inappropriately denied access to medications and treatments that are critical to their health.  
  • An Arthritis Foundation focus group found that patients sometimes feel like they are speaking a different language than insurance providers.  
  • For many patients, understanding the health care system is as difficult as understanding the disease itself. Whether it is a lack of health insurance formulary transparency or too much difficult-to-read language, patients often have a hard time identifying and securing the best health coverage to meet their unique needs.

The Solution

  • Make resource materials easy to understand and incorporate the patient perspective.  
  • Ensure open enrollment materials are accurate so patients can calculate potential costs and choose the plan most appropriate for their treatment.  
  • Disclose all copayment, coinsurance and out-of-pocket cost obligations for each medication.
  • Disclose special requirements for each medication, including step therapy and prior authorization.   
  • Maintain a web-based formulary that is updated within 72 hours of changes and printed disclosures that are updated every three months. 
  • If a formulary is closed or exclusionary, a clear exception process must be available for those excluded drugs deemed medically necessary by the prescriber. 
  • Requirement that notices of an adverse benefit determination, or denial, be made to the plan member in writing within three days of the decision.  
  • Maintain a clear and easy-to-use searchable listing of medications covered in a plan's formulary by medication name and disease type.
  • In the case of an adverse determination, notice of the specific reasons for denial, a patient’s right to appeal, available methods of appeal, and the time period in which an appeal must be made.  

Current Trends

An American Medical Association survey asked roughly 700 physicians about network directories. More than half of doctors see patients monthly who have insurance coverage issues due to inaccurate directories of in-network providers. Two-thirds of physicians want a single interface that updates directory information with multiple health plans.


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