Prior Authorization Reform for Autoimmune and Blood Disorders Act

Key Points

• The bill requires health insurance plans to cover drugs for autoimmune diseases, hemophilia, and Von Willebrand disease, regardless of whether the drug is picked up at a pharmacy or given during a medical visit. This removes a common barrier where insurers refuse to cover a drug based on where it is administered.
• Insurance companies would be limited to requiring prior authorization only once per year for these medications. This means patients and doctors would not have to repeatedly seek approval to continue treatments that are already working.
• There are exceptions to the once-per-year prior authorization limit for short-term drugs, opioids, benzodiazepines, barbiturates, carisoprodol, and drugs that require a special risk evaluation and mitigation strategy under FDA rules.
• The changes apply to group health plans under ERISA, individual and group plans under the Public Health Service Act, and group plans under the Internal Revenue Code, covering most of the private insurance market. The new rules would take effect for plan years starting on or after January 1, 2027.