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Biologics for RA: Costs and Insurance

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.

Turn to the Drug Maker for Help Paying for Biologics

Even with good medical coverage, out-of-pocket costs for biologics can add up. Many drug companies offer financial help for biologics. Most offer reimbursement services to help with your co-pay or other discount programs. Check the drug manufacturer’s web site to find out how the company can help you. Your pharmacist or doctor may also have information on financial assistance.

Reviewed on March 20, 2012

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