Biologics have changed the game when it comes to psoriasis treatment. Your doctor might suggest them if you have serious disease. That means you’ve got plaques on more than 5% to 10% of your body. They’re also used to treat psoriasis in certain areas, like your face, hands, or feet.
Biologics are safe and can clear your skin fast. But they can be expensive. They can cost $38,000 to $65,000 a year or more. That price tag is a lot higher than other psoriasis treatments. For example, 3 years of home light therapy usually costs around $5,000.
Your health insurer will consider several factors before they’ll agree to pay for a biologic, including how much the drug will cost over your lifetime. There’s no cure for psoriasis, so you’ll likely need treatment for many years.
But there are ways to get the medication you need at a price you can afford. Your doctor’s office, drug companies, or nonprofit groups can help. Here are some things to think about to when it comes to insurance coverage and biologics.
What Is a Prior Authorization?
Your doctor might need to give your health plan some extra information about why you need biologics. If so, you’ll have to jump this hurdle before your insurance provider agrees to cover the cost of your medicine. This kind of approval is often needed for costly drugs.
You might hear this process called pre-certification, prior approval, or formulary exception. Here’s how it might work:
- Your prescription goes to the pharmacy.
- The medication is rejected or flagged.
- Your doctor’s office gets notified of the prior authorization.
- A health professional sends the extra info to your insurance provider.
- The pharmacist gets approval and fills your prescription.
This process might delay your medication for a few days or up to a week. Health professionals can often fill out an electronic prior authorization, which may speed things up.
You probably won’t have to do anything while you wait for your medicine. But if your insurer denies the request, the doctor might need to get your written or verbal consent.
What Is Step Therapy?
Doctors are starting to prescribe biologics more often as a first-choice treatment for psoriasis. But many insurers want you to “try and fail” drugs in a certain order before they’ll pay for a biologic. That means you might need to first use topical agents, light therapy, or other oral drugs like methotrexate before moving on to a biologic.
You can find out which medications are cheapest on your health plan. Ask for a list of “preferred” drugs. These may include the biologic that your doctor prescribes or another drug in the same or different class. For example, one TNF-inhibitor might be cheaper than another.
Step therapy is a common reason insurance providers deny coverage for biologics. That’s likely because these drugs are new. But many states have passed laws to bypass this process. It might be easier to get biologics in the future.
If your insurance provider won’t approve your biologic, you can appeal their decision. This might help you avoid switching to a different medication or having a gap in treatment. Ask your doctor for help.
How to Pay for Biologics
Biologics can be costly even with health insurance. But there are ways to lower your out-of-pocket expenses. These include:
Copay assistance programs. These are discount cards or coupons offered by drug companies. They help bring down the cost of your medication after you’ve used your health insurance. Ask your doctor or pharmacist if there’s a copay card that goes with your medicine, or check the drug company’s website.
You can’t use copay assistance if you have a health plan paid by the government. That includes programs such as:
- Medicare
- Medicaid
- Tricare
- Indian Health Services
Patient assistance programs (PAPs). These are cost-saving programs backed by drug companies or nonprofit groups. They’re available to people with or without health insurance. Ask your doctor for more information to see if they’re right for you.
Other resources. Ask your doctor to connect you with a social worker, nurse educator, or biologic coordinator. The Patient Navigator Center at the website of the National Psoriasis Foundation can also point you toward financial help.
Are Biologics Right for You?
Your doctor will consider how psoriasis impacts your life. They’re more likely to suggest biologics if you have moderate-to-severe psoriasis and other treatments haven’t worked.
Here are some questions they’ll consider:
- Does psoriasis cover more than 5% to 10% of your body?
- Are plaques on your face, hands, or feet?
- Does your condition make it hard to move around?
- Do you also have psoriatic arthritis?
Ask your doctor about all the pros and cons. Compared to some other psoriasis drugs, biologics are less likely to hurt organs like your liver and kidneys. But they’re strong drugs that change how your immune system works. It’s good to know how they may affect your body before you get started.
Show Sources
Photo Credit: PhotoAlto / Frederic Cirou / Getty Images
SOURCES:
Keith Choate, MD, PhD, professor of dermatology, pathology, and genetics, Yale School of Medicine.
Journal of the American Academy of Dermatologists International: “Biologics for severe, chronic plaque psoriasis: An Australian cost-utility analysis.”
The American Journal of Pharmacy Benefits: “Psoriasis Treatment Cost Comparison: Biologics Versus Home Phototherapy.”
Comparative Study: “Comparison of the cost-effectiveness of biologic drugs used for moderate-to-severe psoriasis treatment in the United States.”
American Medical Association: “Prior authorization practice resources.”
National Psoriasis Foundation: “Best Practices for Biologic Prior Authorization Process – a Janssen sponsored podcast,” “Getting the Care You Need and Deserve,” “3 States Pass Step Therapy Laws,” “Appealing an Insurance Decision,” “Financial Assistance,” “When Affordability Isn’t a Possibility,” “Medicare Resources,” “Patient Navigation Center.”
American College of Rheumatology Position Statement: “Step Therapy.”
UpToDate: “Treatment of psoriasis in adults.”
Wisconsin Office of the Commissioner of Insurance: “Press Release -- Prescription Drug Step Therapy Changes Go into Effect for Wisconsin Consumers on November 1.”
American Academy of Dermatology: “Psoriasis Treatment: Biologics.”
