Why aren't MS drugs considered maintenance or preventive?

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Should MS drugs bypass the deductible making them more affordable?

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B. No
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C. Yes but not all of them.
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Why aren't MS drugs considered maintenance or preventive?

Post by bsmith » Wed Dec 16, 2015 8:54 am

I work in the prescription insurance business for a very large company that provides prescription coverage for medical insurance plans, company health plans as well as Unions and government agencies.

In the world of prescription drug coverage there are different tiers of medications usually tier 1, 2, 3 and 4. Sometimes they're named Generics, Preferred Brands, Non-Preferred Brands and Specialty meds.

Some medications get special pricing or even zero dollar copays because they're considered preventive or maintenance.

The definition of a preventive drug is: a drug that treats, prevents, or helps to manage a particular disease. Most insurance plans treat prescription drugs on the Preventive Drug List in a way that allows them not apply to the deductible, so you are only responsible for paying the appropriate copay. This enhanced benefit makes it easier for you to purchase the medications you and your family need to stay healthy today – and tomorrow.
The definition of a maintenance medication is: Maintenance drugs are medications prescribed for chronic, long-term conditions and are taken on a regular, recurring basis. Examples of chronic conditions that may require maintenance drugs are: high blood pressure, high cholesterol, and diabetes.
Because of this classification most generic meds in this category are free and most medications in this category will NOT hit the deductible - thus allowing you to avoid even larger issues for not taking them.

WHY THEN if we're including many issues that people are responsible for themselves (high blood pressure, high cholesterol and diabetes) are we not including diseases that people have absolutely no control over? If you over ate and lived a crappy lifestyle your entire life and at 45 need cholesterol pills - free to you, wonderful but someone gets diagnosed with MS and has to meet a high dollar deductible first - how is that fair?

At worst case it should cost the specialty price but not hit any deductibles. These medications are super important to maintaining the disease, keeping it at bay, attempting to avoid the relapse. They fit both or either definition: they treat a chronic disease but do not cure it, they are going to be taken long term (rest of your life) and will be taken on a regular reoccurring basis. They assist in preventing the debilitating symptoms involved with MS. They help to manage it as well.

Someone needs to lobby on this issue for the insurance companies to cover MS drugs at a level that doesn't hit the deductibles. We need affordable generics in the marketplace as well. There is no reason Rebif went from 14K/year in 2012 and now costs 65K/year in 2015!

This is outrageous and someone - I am willing to help and do all I can - needs to help. I'm starting by posting here, getting thoughts, ideas, etc. Perhaps writing a letter to our Senator here in Illinois. It makes no sense to cover diabetic drugs at little to no cost but then slam someone with an even worse disease they got at random for no reason.


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