Arthritis Foundation Legislative Position Statements

Mid-Year Formulary Changes


When selecting a health plan, many people with chronic conditions make their decisions after carefully weighing a complex variety of factors, including plan cost, network adequacy, medication formulary adequacy, cost sharing, the availability of specialists and the choice of hospitals.


Insurance plans sometimes change the available benefits of a policy and coverage of medications during the plan year, imposing new utilization management practices, increasing cost-sharing obligations and making other changes that can have a negative impact on plan members. An insurer unilaterally changing its coverage while requiring insured members to stay in the plan is tantamount to a "bait and switch" technique and is adverse to the interests of people with arthritis.

Arthritis Foundation Position

The Arthritis Foundation supports legislation that keeps insurance coverage consistent and affordable during a plan year and provides the following:

  • Allowance for health insurance plans to increase benefits, coverage or access during a plan year.
  • Prohibition on the removal of a prescription drug from a formulary during the enrollment year.
  • Prohibition on plans from moving a drug to a tier with higher patient cost sharing during the enrollment year.
  • Prohibition on adding new or additional formulary restrictions during the enrollment year.
  • Restrictions that prohibit unfair trade practices and prevent health insurers from making changes to benefits, coverage, utilization management or access during a plan year that negatively impact a plan member.

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