Paying for Biologics for Crohn’s Treatment

What Are the Most Common Costs and Obstacles?

Some people face costs and obstacles that can delay treatment. These are the most common:

Coverage with restrictions: Your health insurance covers these therapies but has rules that delay or limit access.

Step therapy: The insurance recommends cheaper treatments before approving the prescribed biologic.

Prior authorization for advanced therapies: Your health plan requires paperwork showing the treatment is necessary as well as proof of previous treatments.

Differences between insurance plans: Coverage varies by health insurance. For example, Medicare covers infusion therapies under Part B without prior authorization.

People under 65 with commercial plans: In some cases, they need more prior authorizations to access treatment.

Big financial impact: Expenses aren't limited to medications; they also include hospitalizations, doctor visits, and out-of-pocket costs. Other issues include loss of income and having less money to pay for basic expenses like housing and food.

These obstacles are a bigger problem in communities with fewer resources where access to health care services is more limited.

Copayments, Coinsurance, and Deductibles for Biologics

Most health plans cover prescription drugs and hospital care, but if you need long-term biologic therapies, you should consider these significant expenses:

High copays: A set amount you pay each time you receive the medication.

Coinsurance: A percentage of the total cost of the treatment. When the price of the medication is high, this amount is too.

High deductibles: What you must pay before the insurance covers most of the treatment cost.

If you're prepared and follow the right steps, you'll have easier access to your biologic treatment and get the most out of your medical coverage. To prepare:

• Review your policy and what your plan covers.
• Verify that your biologic medication is on your insurance's covered drug list.
• Ask how to appeal a coverage denial with your doctor's help.
• Explore financial assistance programs and manufacturer copay cards.

Biosimilars: A More Accessible Option?

Biosimilars are medications made from living organisms, similar to original biologics, and they can be a more accessible and affordable option.

In general:

• They are similar in terms of safety and effectiveness to their reference biologics.
• They are applied in the same way as original biologics.
• They meet strict standards from the FDA, which reviews these medications to verify they are safe and effective.
• They usually cost less than original biologics.
• They are more likely to be covered by some health insurance plans.

How to Manage the Cost of Biologics

Planning ahead can help you manage your medical coverage better. Avoid surprise costs with these tips:

• Prepare a guide with treatment options (including biologics and alternative therapies) to help you plan for your appointments, tests, and potential expenses.
• Check if the biologic is included in your insurance's drug list and what level of coverage it has.
• Research the cost of telehealth visits and review available opinions to lower travel and appointment costs.
• Contact your insurance to find out your copay, coinsurance, and annual deductible costs before starting treatment.
• Check if the prescribed medication requires prior insurance authorization to avoid delays.
• Explore financial assistance programs and copay cards to lower out-of-pocket expenses.
• Keep bills and medical documents in case you need to file an appeal or request financial assistance.

Weighing the Costs and Benefits

Although biologic treatments can be expensive, they offer long-term benefits:

• They help control Crohn's disease flare-ups.
• They lower your chances of hospitalization.
• They are associated with fewer abdominal surgeries.
• They can lower other medical expenses over time.

Work With Your Doctor and Insurance to Manage Your Treatment

Talk to your doctor and insurance so they can help you understand and choose the best treatment available to you:

• Ask if there are suitable biologic or biosimilar alternatives for you.
• Ask your doctor's office to help you work with your insurance to get prior authorization or file an appeal.
• Check if the treatment is classified as a prescription medication or as a medical infusion, as this can affect the cost.
• Ask about financial assistance programs from the drug manufacturer.
• Ask your health insurance about the estimated cost per dose or cycle and how your deductible works.
• Figure out the requirements and deadlines for getting prior authorization for your treatment.
• Check if the plan requires step therapy and what the appeal process is.

When Is It Time to Change My Treatment?

You should always talk to your doctor before deciding to switch to another treatment. You might make this decision based on your medical needs or your financial situation. These are the most common reasons for switching treatments:

• The biologic stops controlling your symptoms or no longer works well.
• There are newly approved treatments or alternative options that better fit your needs.
• Your health insurance no longer covers the biologic treatment.
• Copays or coinsurance are a significant financial burden.
• A biosimilar or a new treatment offers the same benefit at a lower cost.
• Your doctor recommends a change in treatment for safety or tolerance reasons.

The goal is to find an effective, safe, and practical option for you in the long term.