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MS Patients Are Getting Caught in an Insurance Deductible Snag

June 4, 2018

MS medications are expensive. Many people with MS are able to afford their high prices only because their insurance covers most of the cost, and what remains as their copay is often covered by many of the pharmaceutical companies that produce those meds. The companies offer patient assistance programs or discount cards to pay the copay. Now, however, that paradigm is changing.

If a drug company pays some, or all, of the copay, some insurance companies are now refusing to apply that payment to the patient’s annual deductible. It doesn’t matter that it’s the same amount the insurance company would get if the patient wrote the check. Because the money comes from the pharmaceutical company, however, the insurer won’t count it against the patient’s deductible.

Kristen Catton uses Gilenya and it’s worked well for her, following two disease-modifying therapy (DMT) failures. She’s been on the med for two years and Novartis, which makes Gilenya, has helped Catton pay her $3,800 monthly copay. That’s made the medication affordable for her.

Until recently, that copay assistance counted against Catton’s $8,800 yearly deductible, and it also contributed to reaching her out-of-pocket limit. But recently, the insurance company switched gears. The copay assistance from Novartis would no longer be credited against Catton’s deductible. So, when the copay assistance ran out a few months into the year, rather than having been wiped out, Catton’s deductible was still sitting at $8,800.

The impact this has had on one patient was highlighted in a recent article in Kaiser Health News.

This new process is known in the pharmaceutical industry as copay accumulation. There’s a detailed explanation of how the process works and who benefits on the e-letter Drug Channels. Hint: Employers and health plans save a lot. Patients, on the other hand, may be forced to limit using the DMTs that had been helping their MS in order to afford them.

According to the Kaiser article, that’s what’s happening to Kristin Catton. “I’m talking to my doctor to see if I can I take (Gilenya) every other day,” she says. “I guess I’m winging it until I can figure out what to do.”