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Imagine you have scheduled an MRI or another important treatment vital to your health care and are told it isn’t covered by your insurance until the deductible is met. You point out that you already satisfied the deductible for costly prescriptions, in part through financial assistance from the drug manufacturer. But then learn that assistance doesn’t count.
Welcome to the murky world of “copay-accumulator programs.” First introduced in 2018, this scheme has been used by too many insurers and pharmacy-benefit managers to ensure that only a patient’s own payments count towards deductibles and maximum annual out-of-pocket costs.
For millions of Americans living with chronic diseases, this practice is unfair and harmful. Over 70 percent of respondents to a recent National MS Society survey, for example, reported that they have relied on copay assistance to maintain access to medications essential to managing this chronic disease. There is no cure, and the specific symptoms, progress and severity of MS in any one person are unpredictable.
I know the uncertainty. I found out 31 years ago this month that I have MS. A neurologist, reviewing the report of my first-ever MRI exam, said it was a mild case and could remain that way forever — or change without warning.
My symptoms suddenly changed in 2003, and another neurologist, looking at my second MRI exam films, told me that the disease had advanced and prescribed one of the self-injection drugs to manage its further progression. The Mount Sinai Hospital MS Center is part of my family. Regular visits for routine exams, annual MRIs and taking a disease-modifying therapy, or DMT, to help manage the symptoms have allowed me to continue living the best life I can while living with MS.
Last year, the median cost of the more than 20 DMTs available was $91,835 a year. The oral medication I take costs $100,000. Expensive drugs account for approximately 75 percent of the cost of managing MS. Visits to doctors, bloodwork, MRIs and other medical-care necessities add to the financial burden.
Forgoing any of the treatments, especially the regimen of prescribed medications, could severely worsen my condition. Still, a National MS Society survey found that 40 percent of people who take a DMT were forced to alter or stop taking their medication due to the prohibitive cost. Interrupting one’s medication regimen can have unknown, deleterious ramifications.
That’s why it’s up to individual states to end accumulator programs, especially since an effort to regulate them failed in Congress. New York lawmakers can do the right thing and show leadership by adopting legislation this year.
Assemblyman Richard N. Gottfried and Sen. Gustavo Rivera, the chairmen of the health committees in the Assembly and state Senate, respectively, have introduced bills that would require an insurance policy that provides coverage for prescription drugs to “apply any third-party payments, financial assistance, discount, voucher or other price-reduction instrument for out-of-pocket expenses” to the insured’s deductible, copayment, coinsurance or out-of-pocket maximum.
These bills would safeguard access to life-saving treatments for those living with MS or other expensive chronic diseases, including arthritis and respiratory illnesses, among many others
When drug companies offer financial assistance programs, patients apply for them to alleviate the burdens associated with the exorbitant prices. Many people living with chronic illness are responsible for thousands of dollars in out-of-pocket costs. Copay accumulators unnecessarily prolong the period to cross the deductible threshold, meanwhile jeopardizing access to other medical treatments.
To date, six states — Virginia, West Virginia, Illinois, Arizona, Kentucky and Georgia — have passed legislation to compel insurers to count drug-manufacturer assistance toward deductibles. The Empire State should join them.
Insured New Yorkers shouldn’t have to dig deep into their health-insurance policies to find previously unknown terms and costs. Transparency is vital in health care. Both the Assembly and Senate should move expeditiously to pass, and Gov. Cuomo sign into law, legislation that will ban copay accumulator programs in our state.
Kenneth Bandler, a public relations executive, is a member of the board of trustees of the MS Society, Greater New York City-Long Island chapter.
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