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LEMTRADA is a prescription medicine used to treat adults with relapsing forms of multiple sclerosis (MS). Because of its risks, LEMTRADA is generally used in people who have tried 2 or more MS medicines that have not worked well enough. It is not known if LEMTRADA is safe and effective for use in children under 17 years of age.

View IMPORTANT SAFETY INFORMATION

5 Questions to Ask Your Insurance Company MS One to One By MS One to One • February 8, 2017

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Hi, I’m Denise and I’ve been a nurse for over 30 years—I received my certification for MS nursing in 2014, when I joined the MS One to One program. I’m honored to be an MS One to One Nurse. I’ve helped a lot of patients with questions they have and with other things like benefits verification when they’re looking to start on a different treatment.

So, if you’re on a mission to start LEMTRADA, I want you to know that MS One to One Nurses are here to help. Understanding your insurance policy is really important when it comes to figuring out what the insurance company is obligated to pay for and what your financial responsibility may be. Becoming knowledgeable about what is in your insurance policy can prevent costly mistakes like seeing a physician who is not in-network.

The MS One to One program is also here to help you and your healthcare provider determine your insurance coverage and any additional requirements that may be needed before you can receive LEMTRADA. While MS One to One is working on your benefits verification, you may want to take the time to learn more about this important aspect of starting treatment.

Here are some questions to get you started.

1. Is my healthcare provider and infusion center in-network?

You can find a LEMTRADA-certified prescriber or healthcare facility here. Then you can get in touch with your insurance company or look on their website to see if the healthcare provider is covered in your plan.

2. Do I have a deductible, a co-insurance, and/or any copays?

Understanding the details of your basic coverage is important so you know what your out-of-pocket responsibility may be toward LEMTRADA and the associated costs. You can find out all of this information by contacting your insurance company or visiting their website.

3. Is a prior authorization (PA) required?

I am often asked, “Did my insurance company approve LEMTRADA?” MS One to One obtains coverage details, including deductible and co-insurance amounts, but there may be additional requirements like a PA, which is that additional step that some policies require before “approving” LEMTRADA as a treatment for you. If the PA is denied, MS One to One will get the necessary information to help appeal the denial decision and provide that information to your healthcare provider.

4. What is the name of the specialty pharmacy that my insurance company uses?

There may be more than one contracted specialty pharmacy (SP) that is used by your insurance company. If your healthcare provider chooses to obtain your medication through a contracted SP, the SP may contact you. The SP will explain the coverage details for LEMTRADA and get your permission to move forward with the process. Your MS One to One Nurse can tell you the name of your SP.

5. What if I have Medicaid or Medicare? What do I need to know?

Medicaid Is State-Funded Insurance

An important question to ask your Medicaid provider is if your Medicaid plan has something called a spend-down. A spend-down is also known as excess income. For example, a person may not qualify for state aid until he or she “spends down” the amount of income above the limit for Medicaid eligibility.

Medicare Is a Federal Health Insurance Program

You may not be aware that an individual who receives Social Security Disability Insurance (SSDI) is automatically enrolled in Medicare Part A. Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare. So, if you have SSDI, you also have Medicare Part A.

You may have coverage with a commercial insurer and also have Medicare Part A or Medicare Parts A & B. It is important to know about any secondary insurance you have and communicate that information to your healthcare provider. Unlike Medicaid, Medicare does not require a prior authorization.
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So as you can see, there’s a lot to learn about insurance—but please, don’t be overwhelmed! Once you get the hang of it, you’ll be able to get the information you need—not only about your coverage for LEMTRADA, but for your other medications as well.

And remember, you don’t have to go it alone either. You can always call MS One to One and speak to a nurse like myself, and we’ll be happy to walk you through the insurance process and answer any questions you have. Usually, we can even coordinate with your insurance company when it comes to getting you approved to receive LEMTRADA. Our number is 1-855-676-6326, and someone will always be available to talk to you, day or night.

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