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OUR PRIORITIES: ACCESS

The treatment exists. The rules decide whether you can get it.

Coverage rules, prior authorization, step therapy, and slow coverage decisions sit between patients and care their doctor already chose. We work on those rules.

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Approved isn’t the same as available

A treatment can be approved by the FDA, prescribed by a doctor who knows the patient, and sitting on a pharmacy shelf, and still be out of reach. Prior authorization, step therapy, narrow networks, coverage formulas, and slow coverage decisions all stand between patients and care their doctor has already chosen. We share the goal of health plans and public programs spending wisely. Our work is to make sure the tools they use to do it are clinically sound, timely, and answerable to the patient on the other end. Here is what we’re working on now.

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Protecting coverage from formulas that undervalue patients

Some cost-effectiveness measures, including quality-adjusted life years, assign less value to treatments for people living with disabilities, chronic illness, or rare disease. Congress has already barred Medicare from relying on these formulas, and we support the same protection across every federal health program, so a patient’s worth does not depend on which program covers them.

Read our position →

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Keeping the doctor’s door open

Patients cannot get care from physicians who can no longer afford to see them. We have joined patient and disease groups urging Congress to address the Medicare physician payment cuts that put that access at risk.

Why we support the Patients First Act →

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Covering breakthroughs when they are approved, not years later

When the FDA designates a device as a breakthrough, patients reasonably expect to be able to use it, yet Medicare coverage can lag approval by years. We have urged CMS to close that gap.

Read our comments to CMS →

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State affordability boards and the patient at the end of the rule

When a state prescription drug affordability board sets an upper payment limit, the question for patients is simple: will my treatment still be covered, stocked, and available where I get care? Boards control what can be paid, but not the coverage rules patients actually feel, and we press them to account for that.

Our work on PDABs →

Make your move

Access rules change when the people writing them hear from patients who come prepared. Join the Patients Rising Community, where we are building issue briefs and policy toolkits on these issues for members, take the Advocacy Masterclass, and earn your seat in the Patient Senate. If you are ready to act today, the Action Center has current actions you can take in a few minutes.

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