Jan 27, 2009
Limits in drug coverage saddle MS patients with huge bills
Greater Washington Chapter
A nurse with MS was shocked to discover last spring that her new job would end up costing her more than $900 a month. That’s essentially what happened when she got on her employer’s insurance plan, which didn’t cover Avonex®, her MS disease-modifying drug.
The nurse was able to access the pharmaceutical company’s prescription assistance program to help her pay for the drug through August 2010. After that date, she may be eligible for assistance from the Chapter, but she’s unsure of what the future holds.
“I’m not going to switch drugs after seven years of something working,” she states.
Her dilemma is becoming increasingly common as insurance companies look to contain their costs by restricting patient access to expensive drugs. Under a practice called “tiering,” covered medications are grouped into levels by cost and co-pay.
Tier 1 drugs are the least expensive generics; Tier 2 drugs are the brand-name medicines the insurance company prefers; and Tier 3 drugs are non-preferred, brand-name medicines that are covered only if the patient pays more or tries a Tier 2 drug first.
All MS-modifying drugs are in Tiers 2 and 3, if they are covered at all. A patient on a Tier 2 medication might pay a flat co-pay of $35 a month, while a patient on a Tier 3 drug could be responsible for higher co-pays or percentages of the drug’s cost which can run as high as $3,000 a month.
Insurers differ in what they cover and often change their lists of covered drugs. A Tier 2 drug for one insurer may be Tier 3 for another, or a medication that was Tier 2 last year may now be bumped up to Tier 3.
Patients who see their co-pays increase for drugs they are already taking should consider filing an appeal supported by their doctor, says Seattle neuro-ophthalmologist Eugene May. They can also call the Chapter at 1-800-344-4867 and press 1.
“We can help,” says Dr. May. “Treatment decisions should be based on medical facts and what’s best for the patient, not cost considerations.”