Paying for Treatment

The disease-modifying drugs for MS are very expensive, and thankfully, most insurance carriers in the United States provide some benefits for these treatments. How much coverage you get will depend on your particular policy, so before beginning any type of treatment it is important to ask the following questions:

  • What type of insurance do I have?

  • Is my treatment covered?

  • What will my out-of-pocket costs be?

Not all insurance carriers cover prescription drugs, and those that do might have a list of specific drugs that they'll cover. You must also factor in your monthly copay amount, which will vary depending upon your plan.

Fact

In a 2007 survey of insured people with MS, more than two-thirds of the respondents expressed satisfaction with their insurance coverage, citing comprehensive coverage, overall affordability, and relatively low copays for expensive MS drug therapies as the major reasons for their satisfaction with the coverage.

Financial Assistance

Financial assistance is available from the drug manufacturers for those that qualify. You may also want to turn to Medicare or Medicaid or Social Security Disability Insurance. Following is a list of programs that may be of assistance.

Patient-Assistance Programs

In response to the growing cost of medicine, many pharmaceutical companies now sponsor patient assistance programs. These programs are helping patients who qualify receive medication free of charge. Qualifications vary from company to company, but most are based on income and lack of outpatient prescription coverage. Age is not a factor in order to qualify. To learn more, visit the various pharmaceutical companies online or call their toll-free number.

Pharmaceutical Assistance Programs

Many state governments play a substantial role in offering direct pharmaceutical assistance benefits to eligible residents. Most commonly, individual states offer substantial subsidies to low-and moderate-income seniors. About half these states include younger adults with disabilities among those who are eligible.

A majority of these programs are recognized within the federal Medicare Modernization Act (MMA) and are termed State Pharmaceutical Assistance Programs, or SPAPs.

In the past five years, a growing number of states have started offering state pharmaceutical discount programs. To see whether your state participates and, if so, what the specific eligibility requirements are, visit the National Conference of State Legislatures website (www.ncsl.org) or Medicare (www.medicare.gov/spap.asp).

Medicare Prescription Coverage

Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future.

Everyone with Medicare is eligible for this coverage, including those individuals under the age of sixty-five who get Medicare due to a disability. As with other insurance, if you join, generally you will pay a monthly premium, which varies by plan, and a yearly deductible ($0 to $265 in 2007). You will also pay a part of the cost of your prescriptions, including a copayment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible. You can apply or get more information by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or by visiting www.ssa.gov on the web.

Medicaid

Medicaid was designed to assist low-income families in providing health care for themselves and their children. It also covers certain individuals who fall below the federal poverty level. It covers hospital and doctor's visits, prenatal care, emergency room visits, drugs, and other treatments.

Other people who are eligible for Medicaid include low-income children under age six, low-income pregnant women, Supplemental Security Income recipients, adopted or foster children, specially protected groups, children under age nineteen whose family income is below federal poverty level, some Medicare beneficiaries, and other groups, as determined by each state. Most families that receive welfare probably have a social worker assigned to them, and this person will usually advise a family on its Medicaid eligibility. Your doctor will also be able to inform you about Medicaid. Depending on your state's rules, you may also be asked to pay a small part of the cost (copayment) for some medical services. For more information, visit www.medicaid.gov or call your local Social Security office for more information.

Essential

You may want to look to your community for assistance. There are community-based charitable organizations that may be able to assist you with your drug costs. The Benefits Check Up website at www.benefitscheckup.org is a great resource in helping you identify organizations and programs that can help.

If you're not insured, or your coverage is limited, putting your nose to the grindstone and investing some time in research can really pay off. There is an abundance of programs and organizations whose help you can enlist if you're having a hard time affording a treatment plan. The downside for a lot of people is investing hours filling out forms and plugging their way through the red tape, but your investment of time is an investment in your future.

People who are diagnosed with MS today are in a much better position than people who received the same diagnosis even twenty years ago. And while the new therapies require a commitment from you, they're your best line of defense right now. New and easier treatments are in the pipeline and are eagerly awaited by those in the MS community.

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