Insurance Advocacy
The ACR is working to ensure that insurance policies impacting coverage and payment for rheumatology services are fair and appropriate. The volunteer members of the ACR Insurance Subcommittee help lead this effort by educating payers and advocating for policies that prioritize access to rheumatology care and treatment. Below are updates and resources on key insurance advocacy priorities and information on requesting assistance with an insurance concern.
Insurance Issues
See resources to help with insurance grievances, complaints, and denials.
Members-Only Resources
The ACR is here to help your practice navigate challenging insurance issues.
Filing a State Insurance Department Complaint
Health Plan Complaint FormSpecialty Pharmacy Acquisition Requirements
Numerous commercial insurance companies and pharmacy benefit managers (PBMs) have implemented policies mandating that in-office treatments be purchased through specialty pharmacies instead of the traditional “buy-and-bill” system. In some cases, employers are being given the choice to include these requirements as part of their employee health plan without fully understanding the impact on patient care and access to treatment. These policies threaten patients’ access to critical in-office treatments and the ACR is committed to further educating stakeholders and advocating against them.
Fact Sheet: Protect Access to Physician-Administered Therapies
Members Only Resources
Letter Template - Practice to Patient Employer: Protect Access to Physician Administered Therapies
Site of Service Restrictions for Infused Biologic Drugs
Over the last several years, the ACR has engaged with over ten health plans regarding policies that limit the site of service for patients receiving infusions. These policies aim to move infusions from hospital outpatient facilities to other less costly settings. The policies permit patients to receive their infusions at home, in a physician’s office, or in another non-hospital-based infusion center. Most grant exceptions for initiating or reinitiating therapy and for patients with a history of severe infusion reactions or other medical risks or comorbidities. The ACR continues to dialogue with these health plans and advocate for patient access in a monitored health care setting with on-site supervision by a provider with appropriate training.
ACR Position Statement on Patient Safety and Site of Service for Infusible Biologics
Copay Accumulator Policies
Health plans are increasingly employing copay accumulator policies to limit their spending on critical biologic therapies. When an accumulator is enforced, copay assistance funds are exhausted in the middle of the plan year and patients are forced to pay out of pocket unfortunately, this often necessitates patients discontinuing or switching treatments. The ACR opposes restrictions that prevent the application of funds from assistance programs toward patients’ deductibles and out-of-pocket maximum payments and continues to advocate against such policies.
ACR Position Statement on Programs Limiting Copay Assistance
Members Only Resources
Letter Template - Practice to Patient Employer: Copay Accumulator Policies
Coverage for Apremilast Combination Therapy
The ACR has been approached by numerous members who are struggling with policy restrictions or denials for apremilast (Otezla) when prescribed in combination with a biologic drug. ACR has reached out to payers directly to discuss this issue and also created a template letter for ACR members seeking coverage for individual patients.
Members Only Resources
Letter Template - Practice to Insurance Plan: Coverage for Apremilast Combination Therapy
Tools & Resources for ACR Members
These template letters can be used to help secure insurance approval for off-label uses frequently seen in rheumatology practices.
Off-Label Drug Use Letters
Pediatric Letters
Anakinra – Macrophage Activation Syndrome (MAS)
Biologics – Relapsing Chondritis (RP)
MRI – Temporomandibular Joint (TMJ) Arthrtitis
