Epilepsy is one of Medicare’s six “protected classes” of medical conditions, which means that enrollees with the condition have extensive prescription drug coverage.
An estimated 1.1 million Medicare beneficiaries live with epilepsy, according to the Epilepsy Foundation.
This article provides a brief overview of epilepsy and discusses Medicare coverage. It also looks at costs and how a person can help meet them.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Epilepsy is a medical condition that causes a person to experience seizures. They occur due to a disruption of electrical activity in the brain, which can trigger various symptoms. The Centers for Disease Control and Prevention (CDC) estimate that about 3 million adults in the United States have epilepsy, while around a third of them are aged 55 years or older.
Epilepsy is the third-most-common neurologic disorder affecting older age groups, according to an article in the journal Epilepsy Research. Some of the risk factors that make older adults more likely to have the condition include:
Although doctors commonly diagnose the condition in people younger than 20 years of age, epilepsy diagnosis rates begin to increase after 60 years of age. As most Medicare beneficiaries are aged 65 years and older, they may require medical care for the condition.
However, some younger people may qualify for Medicare due to an epilepsy-related disability that prevents them from working. For example, a person may not be able to obtain a driver’s license if they have had a recent seizure or history of seizures. In these cases, a doctor may certify with the Social Security Administration that the individual is disabled due to their seizures. After a waiting period, a disabled person with epilepsy could receive Medicare coverage.
Federally-funded Medicare provides hospital and medical care for older adults in the U.S., as well as some younger people with disabilities.
The program has four parts:
- Part A provides hospital insurance
- Part B is for medical insurance
- Part C, known as Medicare Advantage, is an alternative to original Medicare’s parts A and B
- Part D covers prescription drugs
Each Medicare part may play a role in helping a person with epilepsy.
Medicare Part A covers a person’s hospital stays, for example, after a seizure. It may also provide coverage for certain epilepsy surgeries, such as removing portions of brain tissue known to cause seizures. However, in these cases, the amount of coverage is decided on a per-case basis.
Medicare Part B generally covers doctor visits and diagnostic treatments when medically necessary. A person may have to cover copays, coinsurance, and deductibles.
Some people with epilepsy may choose to enroll in a Medicare Advantage plan because of the availability of Special Needs Plans (SNPs) for neurologic disorders such as epilepsy.
SNPs offer expanded coverage, including more prescription medications and medical specialists. However, SNPs are region-specific, and a person with epilepsy may need to check if they are available in their area.
Medicare Part D covers several antiseizure medications. However, a person should check their Part D plan’s list of covered medications, known as a formulary, for their specific drug.
Treatments for people with epilepsy aim to prevent the onset of seizures. Many available medications may reduce the likelihood a person will have a seizure.
However, older adults may take several medicines, and doctors need to check that their epilepsy medications do not negatively interact with other drugs.
People should also speak with their doctor about any side effects they experience from epilepsy medications. These drugs are known to cause dizziness and bone loss, which can increase the risk of falls and more serious injuries, such as broken bones.
Doctors may prescribe a combination of medications to treat seizures. When prescribing medicines, they will consider the seizure type and frequency, along with a person’s age, gender, and other drugs.
Sometimes, a doctor may prescribe various combinations of medications before they find the combination that helps control a person’s seizures.
Narrow-spectrum and broad-spectrum drugs
Doctors usually divide antiepileptic drugs (AEDs) into two classes: narrow-spectrum and broad-spectrum.
Narrow-spectrum medications may work for specific seizure types, such as focal, myoclonic, or absence seizures. These drugs include:
- phenytoin (Dilantin)
- carbamazepine (Tegretol)
- oxcarbazepine (Trileptal)
- pregabalin (Lyrica)
- lacosamide (Vimpat)
Broad-spectrum medications may work for a broad variety of seizures, which may help someone who experiences more than one seizure type. These drugs include:
- valproic acid (Depakote)
- lamotrigine (Lamictal)
- topiramate (Topamax)
- levetiracetam (Keppra)
- clonazepam (Klonopin)
AEDs may be available as name-brand medications and generics. Generally, generic medicines will be less expensive than branded drugs. In some cases, however, there may be greater benefits in taking name-brand medications.
Sometimes, a person’s Medicare plan may not cover a certain name-brand drug. In these circumstances, a doctor may contact the individual’s Medicare plan to ask for an exception to make the medication more affordable.
Epilepsy can be a costly condition to manage, especially during the initial diagnosis process. This is because there could be more up-front costs to investigate and start a medication regimen.
According to a study published in the journal Epilepsia, epilepsy costs are higher for those who do not adhere to their medications because they require more hospitalizations and care for seizures.
The study estimated that Medicare beneficiaries paid on average between $718–1,110 every 6 months for their epilepsy care, which includes medications, doctor’s visits, and other diagnostic tests.
A Medicare Advantage or Part D plan may cover many medications. This online tool can help a person search for appropriate prescription drug coverage.
Some plans and programs may help with Medicare-related costs.
- Extra Help: A program available to those with low income, which may help pay for medications.
- Medicaid: This state- and federally-funded insurance program may help a person on low income pay for medications and healthcare costs such as copays and coinsurance.
- Medigap: A Medigap policy may help reduce out-of-pocket costs, such as copays for doctor’s visits or imaging. The policies are not income-based and have a monthly premium.
- Non-profit resources: These resources include the Epilepsy Foundation, the Medicine Assistance Tool, and NeedyMeds. A person can also ask their neurologist if local organizations can help with costs.
Epilepsy is one of Medicare’s “protected classes” of conditions, and people with the condition usually receive comprehensive coverage for relevant medications and treatments.
While there are some exceptions, Medicare plans usually cover at least two AEDs and other treatments. If a person has difficulty paying for their medications, they could be eligible for help to meet these costs.
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