Hi, my Nuerologist has prescribed Tecfidera for me for the last few years. I recently had a baby and haven't taken MS medicine since I found out I was pregnant but will soon go back to him once I have stopped breast feeding.
Tecfidera costs $7000 a month and forces my husband to carry the most expensive insurance his company offers. I don't work and he makes only $17/hour. Between him and I on that highest insurance (it's the only one that will pay for this medicine) we pay $560/month for insurance and that's not including doctor visits or any extras.
Are there more affordable options that my Neuro hasn't offered me that will help my MS? If there is a generic type brand that has proven to work he could carry only the lowest insurance which leaves more money for the kids. (I have a 3 year old and now a 4 month old).
First, I'm an MS patient, not a doctor. Take that FWIW. Second, isn't our immoral, for-profit, private health insurance system wonderful? :) In civilized countries where the gov't helps people, they don't know what the concept of "medical bankruptcy" even is. In Britain, for example, the patient worries about getting healthy and the price of drugs is not even a consideration. Heck, the UK even pays people's transportation costs to go to doctor's appointments (it translates into better health and lower overalls costs).
But to address your question, there are likely a number of factors your neurologist is taking into consideration in making a recommendation for a DMT.
Such things as what he's familiar with and has proven effective in his experience, and also things like your personal risk factors (what he thinks you might get side effects from), to even possibly your specific lesions and the state/stage of your MS and your symptoms. It's worth discussing this with him to get his thinking.
Tecfidera is one of the 3 most effective DMTs. It's generally considered the top 3 DMTs in terms of efficacy/effectiveness are Tysabri (Natalizumab), Ocrevus (Ocrelizumab) and Tecfidera (Dimethyl Fumarate). (I'm not sure of the costs for the others.)
Is the current plan that you have the only one that covers Tecifera at all or is it the plan that provides the lowest cost for Tecficera? If no other plans cover the medication you can see what disease modifying therapies they do cover and talk to your doctor to determine if another medication may work for you. Here is a link to information about the FDA-approved medication for MS. I also encouraged you to call AboveMS, the patient assistance program for Tecfidera and ask if they are able to help you access the medication. Above MS: 1-800-456-2255
I understand that choosing a health insurance plan can be overwhelming, especially for those with several options available to them. Premium Cost is an important factor, but not the only factor to consider when choosing a plan. If you’re comparing the costs and benefits of several plans, here are some things to consider as an individual who is living with MS.
ESTIMATING YOUR HEALTH CARE NEEDS
- How many doctor visits do you have each year?
- What doctors do you see? Include your primary care doctor, specialists, and physical and occupational therapists.
- How many times a year do you get care at an urgent care center or emergency room?
- Have you been hospitalized in the last year? If yes, how many times and how long is your usual hospital stay?
- Do you expect to need surgery or another major procedure in the next year?. If yes, list the procedures you expect to have in the next year.
- Do you take any prescription medications? List any medications you get from a pharmacy, that are sent to you, or that are administered at the doctor’s office.
- Do you anticipate any tests related to your MS in the coming year? Examples may include MRIs or monitoring related to certain prescription medications.
COVERED BENEFITS AND COSTS
- Are the services you expect to need in the coming year covered by the health plan?
- What is the plan’s deductible? Are there separate deductibles for medical and prescription drug costs?
- What are you required to pay for doctor visits? Is it the same for a primary care doctor or a specialist?
- What would you be required to pay for a hospital stay?
- Are there limits on the number of services you may receive per year? This may apply to specific types of services, like chiropractic care or physical therapy.
ACCESS TO PROVIDERS
- Are your doctors, including specialists, and pharmacy in the plan’s network?
- Is your preferred hospital in the plan’s network?
- How much more will you have to pay if your providers are not in the plan’s network and you choose to see them anyway?
- Will the plan require a referral to see a specialist or get other services?
COVERAGE FOR PRESCRIPTION MEDICATIONS
- Are your medications covered by the plan (that is, are they listed on the plan’s formulary)?
- What is the formulary tier for each of your medicines? What is the cost for each tier?
- Will you pay a set amount (a copayment) or a share of the medicine’s cost (coinsurance)?
- Is there a separate deductible for prescription medications? If you take medications but rarely use other health services, you might spend less out-of-pocket if you choose a plan with a low deductible just for medications.
- Is there a separate out-of-pocket maximum for prescription drugs? If you take more than one medication on the highest formulary tier, you may pay less overall if you choose a plan with a separate out-of-pocket maximum for prescriptions.
- What are the options if your provider prescribes a drug that is not on the plan’s formulary?
Lastly, we are aware of one organization that offers a program to help with the cost of out-of-pocket monthly premiums for health insurance. If they indicate they are out of funding when you call, please ask if they have a wait list: The Assistance Fund
I hope this information is helpful. If you have other questions, please call us at 1.800.344.4867 (M-F 7am-5pm MT).
MS Navigator, Stephanie
I am also an MS patient, my neurologist has me on Ocrevus. I was fortunate that he has a relationship with the company & signed me up for the pharmaceutical companies assistance program. I have paid next to nothing for my treatments. I believe contacting the company that produces Tecfidera is the right way to go especially if your treatment is working. I am a single father of two that works 40 plus hours a week while taking care of this dreaded disease. I also had to worry about healthcare coverage for me and my boys when I was diagnosed and its a shame that we have to add to what is already a difficult situation. I wish you all the best!
Have you been able to explore if you are eligible for the "no-copay" plan for Tecfidera? you have to renew it annually, but Biogen (the company that makes it ) offers it. https://www.tecfidera.com/en_us/home/additional-support/financial-support.html. I think you might need to have some sort of insurance, but try reaching out to the company and see if they can help you navigate it.
I'm starting to get in the same boat. Tysabri costs almost $7,000 a month and since my husband retired, I will have to apply to SSA to get Part B of my social security. I wanted to switch to Tecfidera thinking it was cheaper. I feel terrible about your situation and wish there was a way for you to get help.
I am on Tecfidera. I do know Biogen has a patient assistance program and you may be able to get it at a reduced cost or even free. https://www.tecfidera.com/en_us/home/additional-support/biogen-patient-support.html