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.

CVS Caremark Prior Authorization Concerns

Recent changes to the CVS Caremark prior authorization forms for biologic drugs have created additional administrative burden for rheumatology practices. The ACR received many complaints about the changes, chief among these are new criteria around the evaluation of treatment efficacy for continuation of therapy requests.

The ACR has shared these concerns with CVS leadership and received reassurance that they are in the process of streamlining the forms. A revised version is anticipated by the second quarter of 2022.

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
Template Employer Letter from Practices – Physician-Administered Therapies
Specialty Pharmacy Mandates - Media Resources for Practices
Rheumatology Letter to BCBS TN - December 2021

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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