Biologics for RA: Costs and Insurance

From the WebMD Archives

Biologic drugs for rheumatoid arthritis work for 2 out of 3 people who take them for RA. These genetically engineered drugs often slow or halt the progression of joint damage, and they may even push RA into remission. But the drugs are expensive; they cost about $1,000 to $3,000 a month. Even with health insurance, your out-of-pocket costs can add up to hundreds or thousands of dollars.

Here’s what you need to know about paying for biologics if your doctor wants to add one to your RA treatment plan.

Pick the Right Biologic for You

There are nine biologics available for the treatment of RA. Each type targets a specific inflammatory mechanism of the immune system. Some are given as an injection -- a shot under the skin -- others are given by infusing it directly into a vein (IV or intravenously). These drugs can be used alone but are often combined with methotrexate or other RA medications.

Drug Name Brand Name How it is Given How Often
Abatacept Orencia IV or injection IV: Once a month; injection: once a week
Adalimumab Humira injection Weekly or every other week
Anakinra Kineret injection Every day
Certolizumab Cimzia injection Once every 2 to 4 weeks
Etanercept Enbrel injection Once a week
Golimumab Simponi IV or injection IV: Every 8 weeks; injection: once a month
Infliximab Remicade IV Once every 4 to 8 weeks
Rituximab Rituxan IV Two doses, two weeks apart about every 6 months
Tocilizumab Actemra IV or injection IV: Once a month; injection: Weekly or every other week

Biologics are used to treat RA when methotrexate has failed. If one biologic doesn’t work, your doctor will try another one. It may take some time to find the best drug for you.

The other factor to consider when choosing or switching drugs is side effects. With all of the biologics, you are at increased risk of serious infection.

Do You Prefer a Shot or IV?

Biologics can be given as an injection or intravenously (IV). You and your doctor will want to consider what is best and most convenient for you when choosing a biologic.

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Injection

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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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.

WebMD Feature Reviewed by Michael W. Smith, MD on March 20, 2012

Sources

SOURCES:

American College of Rheumatology: Position Statement. Biologic Agents for Rheumatic Diseases.

American College of Rheumatology. Biologic Treatments for Rheumatoid Arthritism, published online December 2004.

Arthritis Foundation. Arthritis Today. “Drug Guide: Biologics”

AARP. Rx Watchdog Report. Published online May 2009.

AHRQ. Agency for Healthcare Research and Quality, published online November 2007.

Consumer Reports. Best Buy Drugs, published online July 2010.

Saag, K. Arthritis Care & Research, published online May 30, 2008.

Janssen Biotech, Inc.

News release, Roche.

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