Insurance Guidelines Lead to Greater Out-of-Pocket Costs for Patients With MS

Samantha DiGrande

The high cost of multiple sclerosis (MS) therapies has created an access problem for patients who can’t afford the medications due to high out-of-pocket costs.

A study recently published in Health Affairs found that Medicare beneficiaries without low-income subsidies will pay more than $6000 a year out-of-pocket on MS drugs alone. The study authors looked to describe changes in pharmacy benefit coverage and cost-sharing amounts for MS therapies in the Medicare Part D program by analyzing enrollment-weighted Prescription Drug Plan Formulary filed from 2007 to 2016.

Interestingly, the study found that for patients who were prescribed the only generic medication in 1 drug class, glatiramer acetate, paid more out-of-pocket than patients using any of the other brand name drugs in the same class.

The authors explained that while the Bipartisan Budget Act of 2018 adapted Medicare payment guidelines to reduce out-of-pocket costs for patients through increased discounts offered by brand name manufacturers, it left patients who use generics with higher out-of-pocket costs for certain generic products.

“This is a pernicious effect of the release of a generic and an unfortunate effect of Medicare rules,” study coauthor Dennis Bourdette, MD, professor and chair of neurology in the Oregon Health & Science University School of Medicine, said in a statement.

Additionally, the authors found that throughout the period studied, the rate of prior authorization increased from 61% to 66% across included plans to 84% to 90%. Prior authorization, used a strategy to manage access to certain expensive drugs or procedures, can delay treatment for patients. Although there has been an increase in MS treatment options, the out-of-pocket costs incurred by patients has continued to increase.

“It’s a dysfunctional market that lacks the typical incentives for most other consumer prices,” commented lead author Daniel Hartung, PharmD, MPH.

The study authors concluded that when writing policy, lawmakers should consider both access restrictions and a growing cost-sharing burden as potential consequences of high and rising drug prices for patients with MS.

Hartun D, Johnston K, Irwin A, Markwardt S, Bourdette D. Trends in coverage for disease-modifying therapies for multiple sclerosis in Medicare Part D. Health Affairs. 2019;28(2).
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