“Preferred” By Whom?

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Certainly, not by multiple sclerosis patients or their physicians. The more MS treatments that are available, the more complicated and confusing is the tiered system of drug prices. A pharmacy benefit provider contracted by an insurer is allowed to decide what is “preferred,” “nonpreferred,” or “not covered.” These decisions are made solely on the basis of the price the pharmaceutical company has negotiated with the particular pharmacy benefit provider. They may use the term “evidence-based” medicine, but no one is fooled. They also fail to consider the total cost of treatment or the consequences of “under-treating” the disease.

Some insurers will no longer cover a disease-modifying treatment that an MS patient has been on for years. They require a switch to a different product because they have negotiated a better price. Patients in California but not in other states are usually protected by Assembly Bill 974, the so-called Gallegos law, which states that an insurer cannot require a patient to stop or change a treatment that has been effective and tolerated for an extended period of time.

Various professional organizations are trying to counter this trend. The National Multiple Sclerosis Society has template letters of appeal on their web site (www. nationalmssociety.org). MS patients tend to be an activist group, and I hope they will protest strongly.

There is a “window of opportunity” that is critical for appropriate treatment. If this opportunity is missed, risk of permanent disability seems to be much higher.

See Practical Neurology, March 2016, page 26.

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