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People With MS Caught in Medicare Donut Hole

  • Published: 2011-05-30 : Author: National Multiple Sclerosis Society
  • Synopsis: People living with MS face high out of pocket costs even when covered by health insurance.

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Finding Critical Relief Under Affordable Care Act in Their Costs For Prescription Medications.

As the average cost of MS in the United States is nearly $70,000 a year, with the overall annual economic cost of MS being an estimated $28 billion, people living with MS face high out-of-pocket costs even when covered by health insurance. The high out-of-pocket costs for medical care and treatment create not only a financial burden but also discourage people from starting and staying on therapy, which right now is the best approach available for preventing disease activity in people with relapsing MS, the most common form of the disease.

As part of the millions of Americans receiving their medical coverage through Medicare, people with MS have already begun to benefit from improvements to the Medicare prescription drug program included in the Affordable Care Act and are now receiving a 50% discount on covered brand name medications bought when they are in the "donut hole." This is particularly important for people with MS as there are no generic equivalents at present for any of the FDA approved disease modifying therapies used by the MS population. For those on symptom management therapies where generic drugs are an option, a 7% discount is now being realized.

"To receive the discount for their prescribed medications, no special action is required, as the discount is automatically applied," advises David Chatel, Executive Vice President, Advocacy at the National MS Society. "It is important, however, that our MS constituency on Medicare know of these new cost savings so that they continue with their needed medications."

Approximately 25% of all people in the U.S. living with multiple sclerosis are Medicare beneficiaries, and most of them rely on Medicare prescription drug plans(Part D) for access to their medicines. But because their drug costs can be exceptionally high, many Part D members with MS hit the 'coverage gap' each year. The coverage gap, or so-called "donut hole," is the period when Part D enrollees must pay 100% of their medication costs. In calendar year 2011 that coverage cap occurs when $2,840 has been spent on needed medications. Prescription drug coverage does not resume until the enrollee has incurred $4,550 in out of pocket medication costs bringing them to the Medicare catastrophic coverage level.

This increased financial relief for those stuck in the coverage donut hole builds on the 2010 one-time rebate of $250 given to Medicare Part D enrollees that hit the donut hole. These initial steps are part of the plan to eliminate the donut hole coverage gap by the end of the decade. These important benefits will improve the quality of life and financial stability of families affected by MS.

About Multiple Sclerosis - Multiple sclerosis, an unpredictable, often disabling disease of the central nervous system, interrupts the flow of information within the brain and between the brain and the body. Every hour in the United States, someone is newly diagnosed with the disease. Symptoms range from numbness and tingling to blindness and paralysis. The progress, severity and specific symptoms of MS in any one person cannot yet be predicted, but advances in research and treatment are moving us closer to a world free of MS. Most people with MS are diagnosed between the ages of 20 and 50, with more than twice as many women as men being diagnosed with the disease. MS affects more than 400,000 people in the U.S. and 2.1 million worldwide.

About the National Multiple Sclerosis Society - The Society addresses the challenges of each person affected by MS. To fulfill this mission, the Society funds cutting-edge research, drives change through advocacy, facilitates professional education, collaborates with MS organizations around the world, and provides programs and services designed to help people living with MS and their families move forward with their lives. In 2010 alone, through its national office and 50-state network of chapters, the Society devoted $159 million to its programs and services that assisted more than one million people. To move us closer to a world free of MS, the Society also invested $37 million to support 325 new and ongoing research projects around the world. The Society is dedicated to achieving a world free of MS. Join the movement at

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