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Summary & Participants
The new Medicare plan goes into effect next year, making it more complex to pay for multiple sclerosis treatment. How do you navigate the maze to make sure your MS care is covered? Here's what experts have to say. Participants: Andrew Pachner, MD Professor of Neurology, University of Medicine and Dentistry of New Jersey Kimberly Calder, MPS Manager, Health Insurance Initiatives; National Multiple Sclerosis Society Editorial Consultant Alice Burton Director, State Health Group AcademyHealth
Webcast Transcript

ANNOUNCER: People with multiple sclerosis can take medications for different reasons. Sometimes it's to treat relapses. Drugs can also treat specific symptoms, such as spasms, stiffness, or pain. Some of the newest drugs, and the most expensive, can help slow the overall progression of disease.

ANDREW PACHNER, MD: The most expensive of these groups is the disease-modifying drugs. Those are the relatively new players on the team and they tend to be very expensive, yes.

Depending upon how payment is made, the costs of the disease-modifying drugs can vary between 16,000 and 24,000 dollars per patient per year.

ANNOUNCER: How do patients pay for these and other medications?

KIM CALDER: From the information that we currently have available, most people with multiple sclerosis have health insurance, including prescription drug coverage. That's quite good. People with Medicare as their health insurer, which is about 25 percent of that population, or roughly 100,000 people do not have health insurance for prescription drugs unless they have it from a source other than Medicare.

ANNOUNCER: Clearly, access to prescription drugs for MS varies a great deal.

ANDREW PACHNER, MD: The costs of drugs for MS is a problem for patients. It's highly variable from patient to patient and from insurance to insurance. Some patients don't take the drugs because of problems with cost.

ANNOUNCER: When the Medicare program was enacted, it did not contain a prescription drug benefit. The MS Society reports a majority of older Americans have traditionally been successful in seeking help elsewhere to defray high drug costs.

KIM CALDER: For people over 65 with multiple sclerosis, access to prescription drugs is generally available to them, and it's generally available through their insurance plan from a former employer or the employer of a spouse, where they get coverage as a dependent, or alternatively they may have assistance through a pharmaceutical assistance program, the actual drug manufacturer.

They may have a discount for prescription drugs through a state pharmaceutical assistance program, or they may be on Medicaid, and therefore have their prescription drugs covered entirely by the state.

ANNOUNCER: 2006 brings a big change in Medicare, a prescription drug benefit.

KIM CALDER: The landscape for people for access to prescription drugs for people with multiple sclerosis under Medicare is changing radically. The Medicare law is changing, and for the first time since the law was enacted in 1965, prescription drug plans will now be available through private insurance policies that are approved by Medicare. Many people will be asked to make a choice about whether or not they want to buy that insurance policy. And they need to understand the consequences of those choices.

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Navigating the Medicare Maze to Treat MS

Webcast Transcript

ANNOUNCER: To encourage participation in the voluntary plan, the legislation calls for an end to many other assistance programs. These include medicare supplemental policies, known as Medigap, as well as assistance programs run by drug companies. So people over 65 and the disabled need to understand how the new prescription drug benefit will work.

KIM CALDER: If you elect to buy this policy, the national average premium will be about 32 dollars a month. In addition to that, you have a 250 dollar deductible toward your prescription drugs. Then for the first 2,250 dollars worth of prescription drug coverage, Medicare or the private plan pays 75 percent of the cost, and you as the beneficiary are responsible for 25 percent of the cost.

At that point, something called the donut hole kicks in, and the plan literally, even though you are still paying a monthly premium, covers nothing until your total prescription drug costs reach 5,100 dollars that year.

Then the catastrophic portion of the plan kicks in and Medicare would cover 95 percent of the drug costs, and you as the beneficiary would only be responsible for the remaining 5 percent of those costs. That benefit is the annual benefit. In other words, you would have to bear those costs every single year.

ANNOUNCER: Let's take an example, for a person with relatively large drug costs, say a person with MS who uses 20,000 dollars worth of medicines each year. The annual premiums will total 384 dollars. The deductible is an additional 250 dollars. The patient then pays 500 dollars toward drugs costing up to 2,250 dollars. Then comes the 2,850 dollar donut hole. Finally, there's 745 dollars, representing 5 percent of the remaining drug costs. The annual grand total for the patient is 4,729 dollars. What happens if these costs remain too high for some people?

KIM CALDER: One of the strongest parts of this law is the funding that has been set aside by Congress to help some people if they are eligible, pay for the policy itself as well as any other out of pocket costs.

There are certain people that are deemed eligible for the financial assistance automatically, but anyone can apply for the financial assistance if they think they may possibly be eligible. To apply for that financial assistance, you would want to contact the Social Security Administration, or you may contact the National MS Society to find out how you might go about applying for this.

ANNOUNCER: Complications abound. Experts say patients must compare the formularies of different plans, to make sure the drug they take is covered. And there will be a penalty for delaying enrollment.

KIM CALDER: I'm a patient advocate and I worry tremendously about the complexity of this plan. I'm not here to say that people cannot do this, but I am concerned that it's very complex. However, there is a lot of help available. There will be help available from Medicare itself, from the Social Security Administration, from the National Multiple Sclerosis Society, from the private plans themselves.

ANNOUNCER: Official Medicare information, and an interactive web tool to help people compare plans in their region, is available at www.medicare.gov. In a national effort so complex as rolling out a Medicare prescription drug benefit, uncertainty is rampant. But so is cautious optimism among doctors and health care experts.

KIM CALDER: The potential strength of this law and the contribution that it makes to the MS community is that people who may not have been able to afford or have access to any prescription drugs in the past may be able to get it. However, it certainly does mean a lot of complexity and confusion in making some sort of transition.

But if at the end of the day there were some people who are not able to be on prescription drugs or certain prescription drugs because they simply did not have coverage for it, this may be a good thing.

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