Lourdes has faced multiple barriers to accessing her multiple sclerosis (MS) medication over several years. Her insurance provider recently denied her access to the medication again. Without treatment, Lourdes' MS symptoms returned, causing damage to her vision and spinal cord. Her neurologist said she needs the medication desperately to prevent further neurological regression. After a lengthy appeals process where the insurance company did not meet required response times, Lourdes was approved for the medication again but expects to have to repeat the battle to maintain access to the treatment she needs.

1. LOURDES DUARTE
Miami, FL
• Lourdes has struggled
with continuity of care
issues to receive access
to her MS treatment.
These issues have posed
a threat to her future.
• Stress is the number one cause of relapse and
exacerbation of MS patients, as well as many other
patients. The current system is not designed to
reduce the burden on patients.
• Patients should not have to jump over
administrative hurdles to receive the medication
that they so desperately need to survive.
Her Story
Lourdes has faced multiple barriers to continuity of care over the
past several years. This year her insurance provider denied her
access to her multiple sclerosis (MS) medication once again.
In 2006, she spent months fighting for access to medication. She
had to provide four medical peer-reviewed journal articles to show
why the drug she had been taking was medically necessary for her
condition.
Lourdes was diagnosed with MS in 1994. The disease, affecting
her central nervous system, has caused her to suffer from
fatigue, numbness in her lower extremities, difficulty walking and
dizziness. Once she was put on her medication, her symptoms
disappeared and she no longer suffered any side effects. Lourdes
has a very active and malignant form of MS that only affects
between one and two percent of patients with MS, which is why
her doctor does not want her using other drugs.
After being without her medication from March to November 2006,
Lourdes’ symptoms returned since being in remission for almost
12 years. Going without her treatment caused plaques, or growths,
to form on her cervical spine. Her vision also completely changed;
her double vision worsened and her optic nerve was damaged.
Lourdes’ doctor, Dr. Sheremata, said that there also seemed to
be regression of her neurological condition and that “we must do
anything we can to get this lady back on effective therapy. Her
future appears clouded at present time unless we can get her back
on her medication.”
After reviewing her case, an Administrative Law Judge found that
the medication she was taking was safe and medically necessary
for her medical condition. Now, only seven years later, Lourdes had
the same problem gaining access to her medication. The Medicare
formulary changed this year, and Lourdes had to go through a
lengthy prior authorization and approval. Furthermore, her insurer
was supposed to respond to the appeal within 24-72 hours, which
they did not do.
When describing the process, Lourdes said, “Nothing is done
quickly, and patients suffer in the meantime. Stress is the number
one cause of relapse and exacerbation of an MS patient. This
is scary for me, because without medication I would end up in
a wheel chair. Everyone is an individual, and as such they need
individualized treatment. My medication works for me, and I need
it desperately.”
Weeks after she submitted paperwork for her appeal, her
insurance company called and informed her that she had been
approved for another year.
“I will most likely have to do this again, but I will continue to fight
and win this battle as long as my health allows me to.”
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