The Insurance Subcommittee (ISC) of the ACR Committee on Rheumatologic Care has had an active start to 2022. High priorities have been advocating for changes to burdensome prior authorization requirements and ensuring continued access to physician-administered therapies.
Prior Authorization
Last summer, CVS Caremark made extensive changes to its prior authorization forms for biologic drugs that significantly increased administrative burden on practices. The ACR received many complaints about the changes, chiefly the new criteria around the evaluation of treatment efficacy for continuation of therapy requests. The ISC has been communicating with CVS leaders to relay these concerns and advocate for specific updates that would help alleviate the burden on rheumatology practices. CVS has committed to revising the forms to help address the concerns, and the new version is scheduled to be implemented on April 1.
Physician-Administered Therapies
In late 2021, Blue Cross Blue Shield of South Carolina (BCBS SC) sent letters to patients prescribed intravenous (IV) biologics that also have self-administered formulations (such as abatacept and tocilizumab) informing them that coverage for the infused formulation would be discontinued as of Jan. 1, 2022. After this date, patients would be required to switch to the self-administered formulation upon expiration of their current prior authorization.
The ISC sent a letter to the payer highlighting the differences between the intravenous and self-administered formulations, reaffirming that the treatment decision falls under the physician’s purview and advocating for continued coverage of IV biologics. In follow-up to the letter, we had the opportunity to speak with BCBS SC leaders, who confirmed that IV therapies are still covered under the medical benefit with a valid prior authorization citing clinical justification.
Access in Rheumatology Meeting
If you are interested in learning more about insurance and access issues, join us in Orlando, Fla., on Saturday, April 30, for the Access in Rheumatology meeting. As part of the 2022 ACR Education Exchange, this meeting will bring together ACR/ARP members, partner organizations, payer representatives and other subject-matter experts to discuss coverage and payment issues impacting access to rheumatology care and treatment. We look forward to seeing everyone face to face for this in-person meeting. See the ACR website for additional information and registration.
The ISC exists to help members with issues related to insurance policies and payers. If you would like the ACR’s help regarding payer issues specific to your own practice or if there is a payer policy you think we should be aware of, reach out to [email protected].
Rebecca Shepherd, MD, MBA, FACR, FACP, is the chair of the ACR Insurance Subcommittee of the Committee on Rheumatologic Care. She is chief of rheumatology and director of the osteoporosis service line at Lancaster General Health in Lancaster, Penn.
