Vanity: Multiple Sclerosis and Cost of Medication

self

[Puddleglum]

To all Freepers and family members who have MS (multiple sclerosis): how much of the cost of your injectable does your insurance cover, if you use betaseron or copaxane or avonex? I was shocked this year to learn my wife's medicine is now a non-preferred drug and that we pay 30% of the cost, which is $500 a month. Now that's a lot better than paying the full price, but it is still very high.

I have always had it covered as a flat co-pay before - say $50.

Are there ways to reduce the cost or do I have to just adjust to the brave new world of shrinking health benefits? I already pay $500+ for my family's medical insurance per month.

Your comments/thoughts/suggestions? I am scrambling to redo this year's budget.

[boxerblues]

My friend deals directly with the manufacturer of Avonex, he receives a discounted rate this way.

[lkco]

Contact the manufacturer, and your local MS society. I'm off the drugs for now (exacerbation free for just over 6 years!), but I remember reading about all the assistance the companies give to people to help pay the costs. I also know the local MS societies are involved with the insurance companies, and that's how many of the drugs got such reduced copays in the first place. Also check your plan for all the other drugs ... some plans only cover some drugs at the lowest rate ... depending on what the pharma negotiates with them ... other pharmas may have better deals with your plan "provider".

It's always a hassle. Our insurance is at $690 premium per month now, and the Avonex, Rebif and Betaseron are all $100 per month ... like all "formularies".

[Brilliant]

I would be interested to know how much Biogen charges for Avonex in Canada. Is this yet another case of the US consumer subsidizing the drug purchases of all of the other people of the world?

[iowamark]

NeedyMeds.com is an excellent directory of drug company Patient Assistance Programs.

It includes qualifications and applications. All 3 of the drugs you mentioned are included.

[codercpc]

At my last job, one of my primary duties was to get insurance companies to pay for things that they denied the first time through. As a disclaimer, I never worked with pharmaceuticals so their procedure may differ. First find out which drugs are on the preferred list. Has your wife tried any of them yet? If yes, the next thing to do is ask her doctor to write a letter of appeal to the insurance company documenting her past treatment, and the advantages that the new treatment has in your wifes individual case. Please remember that the first appeal may not work, in fact it may be best to call the insurance company first to see what their appeal process is.

If your wife has never tried the preferred treatment, talk to her doctor about doing a trial of it, and who knows it may work the same or better, but if it doesn't at least you then have the documentation to help with the appeal.

If all else fails, almost all pharmaceutical companies have medication assistance programs. Look into that. $500.00 a month will put most in a financial crunch in a hurry. Good Luck.

[Puddleglum]

Thanks all for the help and suggestions! I will send my wife this thread's URL so she can follow the info.

[Sam Hill]

This is news? Activism?

[Puddleglum]

unfortunately, all three big name injectables are on the third tier of my pharmacutical formulary (70%/30%).

She has tried all three over the years but has had the best results from betaseron.

[Puddleglum]

This is news? Activism? I selected "Other - Chat." If it is on activism/new, I apologize.

[ClaireSolt]

Your pharmacist should be able to help you get the best deal, if you ask.

[Bogeygolfer]

I've worked with a couple of MS patients and their RX issues over the past few years. The carriers are either classing it as a separate RX coverage as in your case or sometimes covering as a medical expense v. a prescription expense. In a couple of scenarios we went with an HMO classing it as medical and it was 100% covered. My best recommendation now is the health savings accounts. They do vary but here in CA they work great for injectibles. Since everything goes to the deductible including the injectibles you can satisfy your max out of pocket right out of the gates. You know your annual costs to the penny almost. The max out of pocket on an HSA with a $2500 deductible might be $5500 for a family. That's less than your $500 per month right there but you'd also get a lower premium, the tax breaks, and the rest of your family's expenses would be free. Sorry for the incoherent rambling but I'm rushing.

[codercpc]

If there is no generic equivalent that is acceptable, she should still ask her doctor to write the appeal. Even if it doesn't help immediately, a lot of insurance companies keep stats of complaints, and requests, and when they analyze things on an annual basis to reformulate their tiers, they may just reconsider.

I never asked, does your wife self inject? or must she visit the doctors office for the injections? If she doesn't self inject, ask the doctor if this is an option. They will train her how, and then you can have more control over where and when you buy the meds.

Also, call every pharmacy in your geographic area, and compare prices. There are extreme variables in what they will charge. Try especially the "big box" stores (WalMart, Sams Club, Cosco, etc.) they are usually able to buy in bulk and they do pass on the savings. Specialty injectable may differ, but just call and make sure.And get info from your doc about the pharmaceutical drug programs that each company has, there are many options available for more affordable drugs that way.

[Puddleglum]

Yes, my wife self-injects. Oddly enough, the insurance rep told me that if she got injections at a doc's office, each would fall under the office visit copay ($20).

[cgk]

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[cgk]

I agree with coderpc, that you should ask her doctor to write the insurance company and state that it is a necessary medication. When I was taking Rebif - I changed to an insurance plan that didn't cover it - only the 'standard' ABC drugs. The doctor wrote them that it was medically necessary, and that I was already taking it, and needed to continue that same treatment without interruption.

It was a hassle to wait for the order every month, and they were often late by a few days (not good!), but they allowed it.

Otherwise, I'm not sure if your health insurance is from work, or other, but you can also inquire about getting on a medical reimbursement plan (like VitaFlex), if it's available. We have been on one now for a year, and it's a lifesaver when you have constant medical issues.

[dawn53]

What drug does she use?

Does that mean if she used Avonex and went to the doctor's office once a week, she'd only be paying $80 a month versus the 500?

I use Beta, so there'd be no way to go to the doctor's office every other day, plus the cost would be $300 for the month's injections at $20 per doctor's visit.

Both our insurances have had Betaseron as non-formulary, but our non-formulary have a low co-pay of $35.00.

What's the organization that Montel touts in commercials...supposedly they help people get drugs at a discounted rate.

[mware]

The MS society will be your best bet for information.

I know that Neil Cavito has MS, he often speaks about the disease and the medicines he takes.

[Puddleglum]

My wife uses Betaseron. We have discovered that the successor to the Betaseron Foundation will likely cover all but a small copay. I think the paperwork is being processed. I had thought my income + insurance might preclude help, but I guess not.

I appreciate everyone's help and suggestions. My wife and I do need to contact the local MS Foundation here in Oklahoma, just to learn what they offer.

I wonder if any of these medicines will ever have a generic equivalent? Guess I ought to research that, too.