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Potential Cost-Savings for MS Meds & US Insurance Deductibles

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    Potential Cost-Savings for MS Meds & US Insurance Deductibles

    I'm sorry I did not post this at the end of last year or earlier this month to maximize everyone's savings. This is something to keep in mind for 2015.


    US healthcare is often a major expense, especially with a chronic health condition like Multiple Sclerosis(MS). Our MS medications easily run from the $30-60K range on an annual basis, basically forcing companies to have financial assistance programs. By allowing your “co-pay assistance” program to help pay your deductible you can save $100s if not $1000s of dollars.

    For those with an insurance plan with a deductible this post may outline a potential method to reduce your monthly out of pocket expenses and hopefully help meet your annual deductible. Each year, your insurance company expects you to pay your deductible before resuming making most types of payments on your behalf.
    For example, if your deductible is $1,000 you will need to pay the first $1,000 of medical expenses before your insurance company will begin to pay for doctor’s appointments or medications. Your family may have even a larger deductible potentially saving you even more money.
    The good news is most co-pay assistance payments will count towards your deductible. Considering our medications run upwards of $2500/month it is possible that your co-pay insurance plan can cover your entire deductible. If you have a pending large expense (i.e. wheelchair purchase, screening MRI, colonoscopy or other non-emergency surgery, etc.) you may delay them until after your deductible is paid by co-pay assistance and save the out-of-pocket expense.

    How this works:
    1. Review your insurance plan and determine what your annual deductibles are. If necessary, you can contact the toll-free number on the back of your insurance card for assistance. The information should also be available online by logging into your insurance company’s website.
    2. Contact the manufacturer (listed at the bottom) of your MS medication and inquire about their co-pay assistance plan. If you signed up last year, you will probably only need to renew this year. Ensure you write down the necessary information to give to the pharmacy and keep a copy for your records Many programs are limited for those with government-backed healthcare (Medicare/Medicaid/etc).
      My example: I renewed my co-pay assistance plan qualifying for up for $15,000 annually in co-pay assistance. This covers my ENTIRE deductible leaving me with only the minimum $10/month payment. That’s really good for a 15-minute phone call, but set aside a good hour due to hold times.
    3. After you have the co-pay information (i.e. BIN#/PCN/GROUP#/ID#/etc), call your specialty pharmacy to schedule your next medication shipment. Inform them you have co-pay assistance from the drug manufacturer that you want them to apply to your payment. They should process the order and tell you; how much the drug cost, how much the co-pay assistance paid and how much co-pay assistance covered. My co-pay assistance plan paid right at $1700 this month.
    4. Wait 24 hours and contact your insurance carrier and ask them what, if any, of the co-pay assistance payment was applied to your deductible. In some cases, your deductible will be 100% paid, saving you 100s if not 1000s of dollars. If you have a very high deductible it may take a few months for the co-pay assistance plan to zero-out your out-of-pocket expenses.
    5. If you saved money using this method, please consider making a donation to MSWorld or to further MS research.


    Co-Pay Assistance Programs for MS Medications
    MS Active Source (Avonex, Tysabri, Tecfidera): 800-456-2255
    MS Pathways (Betaseron): 800-788-1467
    Exavia Go Program(Extavia): 866-398-2842
    MS Life Lines (Rebif): 877-447-3243
    Shared Solutions (Copaxone): 800-887-8100
    Novartis Patient Services (Gilenya): 877-408-4974
    Aubagio Patient Services (Aubagio): 855-676-6326

    I wish you all well ...

    #2
    This is incredibly welcome information. Thank you for posting.

    Comment


      #3
      Medicare and Tecfidera

      The problem seems to be that Medicare does not have Tecfidera on its formulary. Imperial Washington at work....

      We have Medicare Senior Advantage through Kaiser Permanete. Kaiser, and 9 other Medicare Advantage companies, classify Tecfidera as a Tier 5 Specialty Pharma with co-pays as low as $4,906 per year to as high as 33% (or about $18,000/year).

      We received Tecfidera in 2013 from Biogen through US Biosciences for $0. In December 2013 Biogen said that program would end 12/31/13. Biogen had ACS call us. ACS asked how much we could pay.

      On January 14, 2014 we called Biogen (MS ActiveSource) to talk with Tecfidera team. First they said that ACS could not find funding but to call back when we had 4 days supply of Tecfidera. We called back January 16. During the second call a woman named Rose "rescreened" us. After many minutes, Rose said we would not qualify for any assistance from Biogen. Instead, Rose said, we had to go back to Kaiser Permaente with our tin cup to beg for help.

      On 01/17/14 we picked up the Kaiser "Patient Financial Assistance Program" forms. The first requirement Kaiser imposes is that we call at least 3 community service organizations to beg for help. Then we return to Kaiser with tax returns, bank statements, income verification, etc.

      All this after many years on Tysabri, Avonex and BetaSeron, all with "standard" co-pays.

      Comment


        #4
        Insurance Companies

        are also limiting what's on their formularies as well...

        Comment


          #5
          Co-pay assistance

          Is this based on your income level?

          Comment


            #6
            Originally posted by nkh18 View Post
            Is this based on your income level?
            Each plan has different qualifications, but I was not asked any financial questions. It's definitely worth a phone call to find out.

            Comment


              #7
              Marco

              which DMD are you taking?

              Comment


                #8
                its2much - I've been on Tecfidera since it was released.

                Comment


                  #9
                  My insurance plan doesn't

                  cover that

                  Comment


                    #10
                    co-pay assistance for Ampyra?

                    Do you know if there is help for Ampyra as well as the others listed?

                    Comment


                      #11
                      Ampyra assistance is available:
                      http://ampyra.com/getting-started/financial-assistance

                      Comment


                        #12
                        Thanks Marco.

                        Comment


                          #13
                          When my prescription provider changed, my Amprya deductible went from $40 to $200! I called right away, and although it took a month, Acordia pays $160, and I pay $40. The company guarantees you'll pay no more than $40.

                          Comment


                            #14
                            Originally posted by nkh18 View Post
                            Is this based on your income level?
                            I can chime in and say that the Kaiser plan copays are based around whether it is from an employer or as an individual. I had been on Copaxone a dozen years, until they suddenly (with no notice) informed me that my copay had gone from $40 to 30% of the 'retail cost', which was $1400. My doctor then set me up with Tecfidera, which we found would cost me $1500 copay. My doctor did more searching for me and found the specific membership services number to call for the answer.

                            The answer was; Specialty medications are needed by a small number of people, so when the Health Care bill happened, Kaiser had to find a way to spread the costs around, and that is how they did it.

                            Comment


                              #15
                              Not my insurance

                              I have had trouble for the past 2 years with my insurance capping a prescription at $1500 even though my deductible is $2600 and then an 80/20 for another $1500. Then somehow they stop changing the 20% for prescriptions and only apply that to medical. They are costing me money. Each year I have to fight for months to get it corrected. Those 2 claims were on Gelinya.

                              Now I am on Tecfidera which gives me even more assistance and I don't expect to have any less issue with them for a 3rd straight year. I call the insurance company who never replies to my calls. I have been fighting this Sept-August year since October. By the time it is corrected, it will be time to start all over again.

                              Comment

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