Insurance Advocacy Current Issues

Insurance advocacy


The ACR Insurance Subcommittee and staff are dedicated to working on regional and national insurance issues to secure patient access and fair and consistent reimbursement for providers. Below is information on some of the issues we are currently working on.

UnitedHealthcare Copay Accumulator Policy

As of January 1, 2021, UnitedHealthcare (UHC) will require providers to report the amount their patients receive in copay assistance for office-administered treatments. UHC will then use this information to enforce a copay accumulator, ensuring that no copay assistance funds are applied toward patients’ deductibles or out-of-pocket maximum payments.

The ACR has serious concerns about the impact of this policy on patients’ ability to access treatment. 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, or discontinue or switch treatments. The policy also places providers in an ethically objectionable position by requiring they report information that would be used to harm patients.

The ACR strongly opposes this policy and has urged UHC to explore other ways to rein in drug costs without jeopardizing patients’ health. ACR also led a coalition of provider and patient organizations that joined a letter to UHC advocating against implementation of this policy. We will continue to engage UHC in further dialogue and push for the policy to be completely rescinded.

Provider and Patient Group Letter to UnitedHealthcare - Copay Accumulator Policy
Template Employer Letter for Practices - Copay Accumulator Policies

Medicare Contractors Delay Addition of Stelara to SAD List

In March, most of the Medicare Administrative Contractors (MACs) announced plans to move Stelara to the Self-Administered Drug (SAD) with effective dates ranging from April 20-May 3, 2020. Moving this drug to the SAD list would prohibit patient access under Medicare Part B.

The ACR opposes moving Stelara to the SAD list, particularly during the current health crisis we’re facing as a result of the COVID-19 global pandemic. ACR reached out to each of the MACs individually and also led a multispecialty sign-on letter to CMS urging them to weigh in and advise the MACs to delay this change.

The MACs have subsequently decided to delay the addition of Stelara to the SAD list until 45 days after the end of the public health emergency. The ACR remains concerned about the appropriateness of moving this drug to the SAD list and the impact of this decision on patient access. Doing so would leave vulnerable patients with limited treatment options. ACR advocacy efforts will continue to prioritize protecting Part B access to this drug.

Multispecialty Sign-On Letter to CMS - Addition of Stelara to SAD List
Rheumatology Sign-On Letter to CMS - Addition of Stelara to SAD List

Mandated Specialty Pharmacy Acquisition of Physician-Administered Treatments

Several 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.

Blue Cross Blue Shield of Tennessee (BCBST) announced last fall that all specialty drugs would have to be acquired through the BCBST specialty pharmacy network as of January 1, 2020. After significant opposition from stakeholders, including the ACR, BCBST pushed back the implementation date of the policy to July 1, 2020. ACR has subsequently requested further delay during the current COVID-19 public health crisis; however, the payer remains committed to moving forward with the planned implementation date.

The ACR is very concerned about the impact of these policies on patients’ access to critical in-office treatments. We are providing education to patients and employers regarding the potential harm of these policies and will continue to advocate against the policies proposed by BCBST and other payers. In light of the unprecedented challenges faced as a result of COVID-19, ACR will also continue to urge payers to delay any policy that would increase administrative burden or disrupt patient care so that members can remain focused on patient care at this critical time.

Fact Sheet: Protect Access to Physician-Administered Therapies - March 2020
Template Employer Letter from Practices – Physician-Administered Therapies
Specialty Pharmacy Mandates - Media Resources for Practices
Rheumatology Letter to BCBS TN - December 2019
Multi-Specialty Letter to BCBS TN - February 2020

Site of Service Restrictions for Infused Biologics

Since 2015, the ACR has engaged with ten different health plans regarding policies that limit the site of service for patients receiving infusions. The payers implementing these policies have the stated goal of moving 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 as well as patients with a history of severe infusion reactions or other medical risks or comorbidities. The ACR continues to dialogue with these health plans as we 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

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