Most people with rheumatoid arthritis (RA) start their treatment with conventional disease-modifying antirheumatic drugs, or DMARDs. But if these drugs don't work well enough to reduce inflammation and pain in your joints, your doctor may recommend biologic DMARDs.
Biologic drugs are proteins that are genetically engineered in a lab to target parts of your immune system that cause inflammation. You get them by shot or IV.
Because they're harder to make than conventional DMARDs, biologics cost more -- a lot more. How much depends on the medication. But the cost can range from $1,300-$3,000 a month to $5,000 per week, before insurance.
That kind of price tag can make you lose sleep over your finances rather than focus on your recovery. But there are ways to make biologics for RA more affordable. As always with health care, you'll benefit from a proactive strategy.
Insurance and Biologics
The types of biologics your doctor may recommend for RA include:
- Tumor necrosis factor (TNF) inhibitors like adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), and infliximab (Remicade)
- B-cell inhibitors like rituximab (Rituxan)
- Interleukin inhibitors like sarilumab (Kevzara) and tocilizumab (Actemra)
- Selective co-stimulation modulators like abatacept (Orencia)
- JAK inhibitors like tofacitinib (Xeljanz) and upadacitinib (Rinvoq)
Most private health insurance plans cover biologics for RA. So do Medicare Part D and Medicaid. But private health plans vary widely in:
- Which drugs are covered
- What you have to do before the insurer will pay
- Co-pay amounts
Even if the biologic you want is covered, deductibles and drug copays can add up fast. Even with Medicare Part D, one study estimated annual out-of-pocket costs for RA biologics at $4,800 or more.
Insurance Coverage Appeals
If your insurer doesn’t want to cover the biologic your doctor recommends, that doesn't have to be the end of the story.
You can file an appeal with the insurance company if it won’t authorize coverage or denies your claim, says Caitlin Donovan, senior director of public relations with both the National Patient Advocate Foundation and the Patient Advocate Foundation.
“While appeals can be a huge pain because it’s almost a legal argument, we always recommend going through the process,” Donovan says. “Hopefully, your doctor’s billing office can also help you with an appeal.”
The Patient Advocate Foundation offers free online templates for appeal letters, plus guidance on the process.
Working With Your Doctor
Your doctor can be an asset in making your RA medication more affordable. But you have to bring up the subject.
“I hope nobody feels reluctant anymore about having this discussion,” says Nancy Carteron, MD, a rheumatologist with the University of California-Berkeley and a director at the HealthWell Foundation.
“Your doctor will be happy to talk about whether the advantages of the best option for the patient are worth the cost, before kicking it over to the insurance company.”
For example, your doctor may be able to prescribe a less expensive biologic or a conventional DMARD that will give you relief from inflammation and pain. Or they might have free samples of medication on hand that will save you money for a while.
Biosimilar medications are another cost-saving alternative to discuss with your doctor. These are essentially copycat biologics. They're made from the same sources, with the same benefits, strength, and dosage. The FDA has approved the biosimilars infliximab-axxq (Avsola), infliximab-dyyb (Inflectra), and infliximab-abda (Renflexis) to treat RA.
But bear in mind that their price advantage over biologics isn't always a big one.
“It’s not clear why that is, and it all depends on the drug,” says Joel Lexchin, MD, of the York University School of Health Policy and Management. “The list price gap might be as low as 10%-15% or as high as 40%-50%.”
Assistance Programs and Discounts
Maybe even after you negotiate with your insurance company and work with your doctor, it’s still hard to afford your biologic. You have more options to research:
Drug manufacturers’ patient assistance programs (PAPs). These may offer a biologic free to low-income people. For others, they might cover all co-pays for a few months and a portion of them after that. They might even reimburse you for transportation to an infusion center. You can search online for assistance programs offered by makers of arthritis medication.
Remember that a company's PAP will only help you with that manufacturer’s drug, Lexchin says. If that's not your preferred biologic, he thinks it’s a good idea to compare your costs using the PAP with those of taking a conventional DMARD. “The more comparative information you get, the better off you are,” he says.
Also, “expect a lot of red tape,” Donovan says. With most PAPs, you need to provide lots of information about your medical history. Your doctor’s office will need to validate your RA diagnosis and biologic prescription. And a PAP may have an income limit.
State PAPs. The federal government's Medicare website has a page where you can check whether your state has a PAP. These may help pay your insurance premiums or drug copays. Often, these programs are for the elderly or people without a drug plan.
“These are usually paper-based programs with longer application-processing times,” Donovan says. “Usually if you are looking at one of these programs, you are not on Medicaid already.”
Private foundations and nonprofits. There's a long list of organizations that might help you cover the costs of your RA medication. A few of them:
- The Good Days organization helps pay for your out-of-pocket costs for Cimzia, Humira, or Remicade.
- The Patient Advocate Foundation has a co-pay relief program that covers any medication for a particular condition.
- NeedyMeds offers a drug discount card good for 80% off prescriptions at participating pharmacies.
- The Assistance Fund has a program that covers copays and deductibles for medications including RA biologics.
- The Patient Access Network helps underinsured people pay for RA out-of-pocket and treatment expenses.
If you're considering one of these groups, Carteron suggests you start by researching whether:
- It has a fund for people with RA
- That fund is accepting new applications
- Whether your income, insurance coverage, or home state make a difference
Some of these groups get donations from drug manufacturers, so they have an incentive to steer you toward that company’s biologic, Lexchin adds. Contact the foundation or nonprofit to ask about any limits on what medication they help with.
Discounts at the pharmacy. Biologics often come from specialty pharmacies, so the general discount programs run by some pharmacy chains won’t help you. But maybe discount cards can. GoodRx, for example, lists coupon prices for Humira, Enbrel, and Remicade, among other medications.
Strategize, Then Act
There are many tactics and resources available if you think a biologic is your best chance for success with your RA treatment. Don’t let sticker shock stop you before you get started.
Photo Credit: Rob Daly / Getty Images
Arthritis Foundation: “Biologics” and “Biosimilars: What You Should Know.”
Arthritis & Rheumatology: “Coverage for High Cost Specialty Drugs for Rheumatoid Arthritis in Medicare Part D.”
Caitlin Donovan, senior director of public relations, National Patient Advocate Foundation and Patient Advocate Foundation, Washington, D.C.
Centers for Medicare and Medicaid Services: “Pharmaceutical Manufacturer Patient Assistance Program Information.”
Consumer Reports: “Using biologic drugs to treat rheumatoid arthritis: Comparing effectiveness, safety, side effects, and price.”
Health Affairs: “The Economics of Biologic Drugs: A Further Response to Bach et al.”
Joel Lexchin, MD, York University School of Health Policy and Management, Toronto, Ontario, Canada.
Johns Hopkins Arthritis Center: “Rheumatoid Arthritis Treatment.”
Journal of the American Medical Association: “Assessment of Expected Out-of-Pocket Spending for Rheumatoid Arthritis Biologics Among Patients Enrolled in Medicare Part D, 2010-2019.”
Journal of Managed Care: “Variation of Private Payer Coverage of Rheumatoid Arthritis Drugs.”
Kaiser Family Foundation: “Medicaid’s Most Costly Outpatient Drugs.”
Medicare.gov: “6 ways to get help with prescription costs.”
Nancy Carteron, MD, FACR, University of California-Berkeley and Director of HealthWell Foundation, Germantown, MD.
Rheumatoid Arthritis Support Network: “RA Costs: What are Payment Options for Treating Rheumatoid Arthritis?”