Broader Medicare drug coverage linked to fewer relapses in MS patients.
Medicare prescription drug coverage plays a major role in the treatment options available to older adults living with multiple sclerosis, and new findings suggest that these options, or the lack of them, may be making a real difference in patient outcomes. Researchers at the University of Southern California studied over 85,000 people with the relapsing-remitting form of MS and found that those with broader drug list options and access to medications experienced fewer relapses. While that might seem expected, the study puts real numbers to the consequences of restricted access under current Medicare Part D plans.
The data show that many Medicare drug plans cover only a small selection of the 15 approved oral and injectable drugs used to manage MS. These medications fall into different categories, based on how they act in the body, and physicians often rely on trial and error to find the most effective one for each patient. The study found that standalone drug plans tended to include just four of the available drugs, while Medicare Advantage plans typically included eight. Those with access to more drug types saw a noticeably lower chance of relapsing in the following months, an 8 to 12 percent drop for Medicare Advantage plan members and 6 to 9 percent for those with standalone plans.
These differences matter. MS is a condition that affects the central nervous system and can severely impact movement, vision, and thinking. While there’s no cure, modern drugs can slow the disease’s progress and help reduce flare-ups. But that depends on access. When coverage is narrow and drugs are left off formularies, the drug list a plan agrees to cover, patients may go without the treatment they need. This can lead to worsening symptoms and greater long-term costs for both individuals and the healthcare system.
One reason for the narrow coverage is the growing use of pharmacy benefit managers to control costs. These companies act as middlemen between drug manufacturers and insurance plans, negotiating lower prices in exchange for putting certain medications on the plan’s drug list. Sometimes they exclude newer or more expensive drugs to pressure manufacturers into lowering prices. While this may work for common conditions with generic alternatives, it poses a problem for diseases like MS, where one patient’s success with a drug might not work at all for someone else.
Adding to the challenge is the fact that MS medications are expensive, often ranging between $5,000 and $10,000 per month. And because these drugs aren’t in Medicare’s protected categories, there’s no requirement to include them. As the government begins to cap out-of-pocket costs for Medicare drug plans, insurers may face even more pressure to control their spending, potentially leading to more exclusions.
Researchers say there are ways to address this. Alternative payment models, such as subscription-based pricing or outcome-based agreements, could help plans afford wider coverage. In one model, a plan might pay a flat fee for unlimited access to certain drugs. In another, manufacturers might be paid based on how well the treatment performs. These ideas are already in use in some areas of healthcare and could be adapted to better support patients with chronic or serious conditions.
Ultimately, the findings highlight the link between insurance design and health. While the goal of saving money on prescription drugs is understandable, it becomes risky when those decisions limit treatment options for people with life-altering diseases. For those with MS, the path to stability often depends on trying multiple therapies before finding the one that fits. Narrow drug list options place people at greater risk of decline.
Sources:
Narrow Medicare drug coverage linked to worse outcomes in MS patients
Formulary Restrictions and Relapse Episodes in Persons With Relapsing-Remitting Multiple Sclerosis
Join the conversation!