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Transparency of Coverage & Cost

When living with a chronic illness like multiple sclerosis or any medical condition that requires a prescription drug regimen, it is critical that prescription drug benefits remain constant during the entire annual term of a health insurance contract. When the cost or access to a drug changes unexpectedly, it creates a barrier to continuity of prescription drug coverage.

An unexpected change in coverage—especially an increase in cost for prescriptions that already cost hundreds of dollars or more a month—can be difficult for a family to absorb, often leaving no option but to cut back on a drug’s use or stop taking it altogether.

Most health care plans use “tiers” as a pricing structure for prescription drug benefits, each with a set cost-sharing amount—for example, $10 for generic, $30 for preferred and $60 for non-preferred. It is increasingly common for plans to have a fourth level known as a “specialty tier,” where the enrollee's financial responsibility increases to “co-insurance,” or a percentage of the drug’s cost.

For persons living with MS, the disease modifying drugs (FDA approved medications to delay progression of the disease) almost always are covered in the “specialty tier.” The cost increase at this level is substantial, often in the hundreds of dollars a month and sometimes in the thousands.

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