Paying for Biologics for Ulcerative Colitis

Health Insurance Coverage for Biologics

Most health insurances cover biologic therapies, including private plans, Medicare, and Medicaid. Your individual plan details determine how much you pay out of pocket and when you can start treatment.

Insurance usually covers biologics when:

• Ulcerative colitis is moderate or severe.
• Other treatments haven't worked.
• The biologic is approved by the FDA.
• Your doctor gets prior authorization, which involves sending paperwork to show the treatment is necessary.
• Step therapy requirements are met, meaning you've tried other treatments first.

How and where you get your treatment also affect costs. The way you receive your biologic can impact how much you pay and how much counts towards your deductible.

In general:

• Intravenous (IV) infusions are covered as a medical benefit by your insurance, which applies to treatments given at a healthcare facility.
• Shots you give yourself at home are usually covered as a pharmacy benefit, which includes medications you get at a pharmacy or specialty pharmacy.

Copays, Coinsurance, and Deductibles for Biologics

Even if your insurance covers the medication, you might still have to pay a large part out of pocket. This happens when your plan has a high deductible or high coinsurance. That's why it's important to carefully review the details of your policy and confirm them directly with your insurance.

Copay: This is a fixed amount you pay each time you receive treatment, like an infusion or a prescription.

Coinsurance: This is a percentage of the total cost of the medication you must pay. If the treatment is expensive, that amount can be high.

Deductible: This is the amount you must pay before the insurance starts covering most of the costs.

Biosimilars: A More Accessible Option?

Biosimilars are medications made from living organisms, similar to original biologics, and they can be a more accessible option. They are approved by the FDA.

In general:

• Biosimilars usually cost less because they follow a different approval process than original biologics.
• They encourage market competition, allowing insurance plans to negotiate better prices and prioritize their coverage.
• They can lower costs, as you pay less in copays and coinsurance and it's easier for your insurance to approve these medications.

How Does Ulcerative Colitis Affect the Hispanic Community?

For many families, the challenges they face affect both their health and their finances. These difficulties are often felt more strongly in the Hispanic community due to gaps in coverage and barriers to accessing health care.

In general:

• Hispanic people with ulcerative colitis face more obstacles to accessing medical care, such as insufficient coverage, limited job options, or language barriers.
• The Hispanic community has higher rates of hospitalization and mortality, even though the disease is not more common than in other groups.
• Medical costs can be higher, with average yearly expenses of $63,349 per person, compared to $38,240 for other groups.

Tips for Managing and Preparing for the Costs of Treatment

Before starting any treatment, it's a good idea to talk with your doctor and your insurance company to understand your costs and make informed decisions. You should:

• Ask if the biologic is covered as a medical benefit or a pharmacy benefit, as this difference can affect how much you pay and how much counts towards your deductible. 
• Check how your deductible, coinsurance, copays, and out-of-pocket maximum work.
• Learn about prior authorizations and step therapy, and find out what paperwork is needed and how long approval usually takes.
• Keep a simple record of your treatment and expenses, including dates of your infusions or prescriptions, calls to your insurance, letters received, and amounts paid.
• Explore financial assistance options from the start of treatment, rather than waiting until costs become hard to manage.
• Look for manufacturer support programs when available, such as copay cards, assistance programs, and help coordinating benefits.
• Ask for help if your insurance denies coverage. Your doctor's office can help you file appeals and handle prior authorizations and medical paperwork.

When Is It Time to Switch to Another Treatment?

If you have moderate to severe ulcerative colitis, having several biologic options allows you to adjust your treatment over time to better control your symptoms.

Consider making a change when:

• Symptoms persist or return despite treatment.
• The treatment doesn't work as expected, which can lead to more doctor appointment, ER visits, or hospitalizations.
• Costs increase due to not responding to the current medication.
• You find an alternative that better suits your needs after talking to your gastroenterologist about other options.