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Biologics for RA: Costs and Insurance

Do You Prefer a Shot or IV? continued...


IV Infusion

You give yourself a shot at home -- convenient, but some people are uneasy about giving themselves a shot.

You may be able to go to your doctor’s office to get the shots.

Must be given at a hospital or clinic.

Risk of injection site reactions such as rash, burning, or itching.

Kineret had the highest rate of injection site reactions, according to an analysis by Consumer Reports in 2010.

Risk of infusion reactions including itching, hives, rash, nausea, and headache.

Rituxan had the highest rate of infusion reactions and Orencia the lowest, according to the 2010 Consumer Reports analysis.

Shots are needed more frequently than infusions.

Frequency ranges from daily shots to a shot every month.

Infusions can take several hours but are usually only needed every month or two.

Infusions may be needed more often during the first year of treatment, which can increase initial costs.

Find Out if Biologics Are Covered by Your Insurer

Biologics are some of the most expensive drug treatments available. They can cost between $10,000 and $30,000 a year. Although many insurance plans cover biologics at some level, you usually have to pay a percentage of the cost. And getting your insurer's approval for the drugs can take time. Here are five tips to help you get started.

  1. Check your individual policy to see if biologics are covered and what your co-pay is.
  2. If it is covered, find out if drug costs apply to your out-of-pocket maximum; most of the time they won’t.
  3. You may need pre-authorization from your insurance company before treatment can start. This may require your doctor to call or write your insurance company for approval.
  4. Sometimes coverage is initially denied. In this case, you and your doctor may need to do additional legwork to facilitate an appeals process.
  5. If you are considering switching insurance plans, be sure to find out what the new plan covers before you enroll.

Be sure to have a frank talk with your doctor about the biologic recommended for you. Share any concerns you have. There may be an equally or more effective biologic that costs less.

Taking a long-term view, evidence shows that all the biologics aggressively slow the disease, which may ultimately reduce the overall cost of managing the disease by reducing complications, long-term disability, and the need for surgery.

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