The Real Cost of Biologic Drugs
Biologics are innovative medications for people with chronic diseases. They are effective treatments for asthma, allergies, and skin diseases. They are also commonly used for cancer, Crohn’s disease and rheumatoid arthritis treatment.
Biologics are very expensive medications. Fortunately, many patients can get help with the cost. Private, commercial health insurance may cover a significant portion of the price. Patient assistance programs from drugmakers are available for those who qualify.
Biosimilar drugs, which are like generic versions of biologics, are increasingly available. They may help lower costs over time.
How much do biologic drugs cost?
The cost of biologic drugs can range from a few thousand to tens of thousands of dollars per year. The biologics prescribed to treat asthma, allergies, eczema and urticaria are about $3,000 to $5,000. Some biologics for treating arthritis may cost around $10,000 to $30,000 a year. In some cases, biologics for more serious conditions, like certain cancers, can cost even more, up to $100,000 a year or higher.
Biologics account for 2% of prescriptions, but 37% of net drug spending. The total is more than $120 million every year. Rising drug prices are a concern for many. Private and government insurance, patient assistance programs, and drug alternatives are important to help lower costs.
Biosimilar drugs are generic versions of biologics and the cost is less than their biologic counterparts. They have similar effectiveness and side effects. Biosimilars can help patients and healthcare systems access essential treatments.
Why are biologics so expensive?
The reason biologics are costly is because they are so complex to make. They are derived from living cells, unlike traditional drugs which are made from chemicals. Scientists need advanced technology to create biologics. It takes a long time to undertake drug discovery, develop and test these medications to make sure they are safe and work well.
Another reason biologics are so expensive is the cost of research. It takes years and millions of dollars to research, test, and bring a biologic medication to the market. They are only available as injections or infusions. The medications are in high demand and have few competitors, which also drives up the costs.
Biologics require long research studies and clinical trials. Also, not every pharmacy can provide them, which can make distribution more difficult.
Biologics have strict rules about how they are handled and stored. They can be sensitive to temperature and other factors. This adds to the cost of getting the medicine to patients.
Are biologics covered by insurance?
Since biologics are so expensive, many people wonder if their health insurance will provide coverage. The good news is that most health insurance plans do cover biologic medications. However, the amount of coverage depends on the specific plan. Some insurance companies may pay for most of the drug costs, but others may require you to pay a large part yourself. This is your copay.
Some private and government health insurance may require prior authorization from your doctor before approving coverage of a biologic. Sometimes, you may need to try less expensive treatments first before your insurance will cover a biologic.
Some insurance plans have specialty tiers for each biologic drug. This can mean higher out-of-pocket costs for the patient. Most pharmaceutical companies offer patient assistance programs, and sometimes doctors can help you find ways to lower the drug cost.
If you are prescribed a biologic, be sure to pass on all necessary insurance documents to your doctor. If your insurance denies the medication, you may be able to file an appeal with the help of your doctor.
Are biologics covered by Medicare?
Medicare is a government insurance program that helps people over 65 or those with certain disabilities pay for healthcare. Medicare does cover most biologic drugs, but it depends on the type of Medicare plan you have.
The two parts of Medicare that cover biologic agents are:
- Medicare Part B: If your biologic injection or IV is given by a doctor in a clinic or medical facility, Part B may cover it. Part B covers outpatient care, like doctor visits and certain medications that you get at a doctor’s office or clinic.
- Medicare Part D: If you take your biologic injection at home, Part D may cover it. Part D covers prescription medications taken at home. Each Part D plan is different, so you will need to check if the specific biologic you need is covered.
Even if Medicare covers your biologic medication, you may still have a copay. You might also have to meet a deductible before Medicare starts paying.
Biologics patient assistance programs
Drug manufacturers offer patient assistance programs and copay assistance programs for people who are prescribed biologics. These programs help people better afford biologics with out-of-pocket costs such as copays.
The programs are available for people with private health insurance and for people who are uninsured or under-insured. They are not available to people with insurance paid for by the government. This includes Medicare, Medicaid, Tricare, or Indian Health Services.
Each biologic has different eligibility requirements for patient assistance programs.
Adbry (tralokinumab)
The Adbry Advocate™ Program offers copay support for people with commercial insurance. Under the copay program, people would be reimbursed for the costs of the medication, paying as little as $0 per dose. The maximum amount available is $13,000.
Adbry’s Bridge Care™ Program helps eligible, commercially insured people whose insurance does not yet cover Adbry. They can get a maximum of six months of Adbry within a 2-year time period or until insurance covers Adbry.
Cinqair (reslizumab)
The CINQAIR Cost Support Program is available for people with commercial insurance. It helps without-of-pocket costs for the drug and administration. It provides assistance of up to $10,000 yearly. Eligible patients may pay as little as $0.
Dupixent (dupilumab)
Dupixent MyWay® is available for people with commercial insurance. With this program, eligible people may pay as little as a $0 copay using the DupixentMyWay copay card. People can also request copay reimbursement if their copay card is not accepted or if costs were paid before enrolling in the program. The maximum amount of coverage is $13,000 per calendar year.
Ebglyss (lebrikizumab)
Lilly, the manufacturer of Ebglyss, offers a Lilly Support Program that includes a Savings Card. With this program, people with a commercial insurance plan that covers Ebglyss are eligible to pay as little as $5 each time they fill a monthly prescription, up to $9,450 per year. If the commercial insurance plan does not cover Ebglyss, then people may be eligible to pay as little as $25 each time they fill your monthly prescription.
Fasenra (benralizumab)
The Fasenra 360 Savings Programis available for people with commercial insurance. If you are eligible, you may pay as little as $0 for Fasenra. The program covers any out-of-pocket costs up to $13,000 per calendar year. These out-of-pocket costs may include the cost of the product itself, the cost of the injection, and injection training.
Nucala (mepolizumab)
The Nucala Copay Program is available for people with commercial insurance. Eligible patients may be responsible for as little as $0 for their Nucala medication. You must fill out an enrollment form to qualify. Eligibility is reassessed each year. The maximum amount available under the copay program for most people is $9,450 per year. The maximum amount for people who are in a high-deductible health insurance plan is $15,000 per year.
Xolair (omalizumab)
The Xolair Co-Pay Program is available for people with commercial insurance. It provides financial assistance of up to $15,000 yearly for drugs costs and and/or up to $1,500 yearly for injection costs. Eligible people enrolled in the program may pay as little as $0.
The Genentech Patient Foundation provides complimentary Xolair doses to individuals who have been prescribed the medication and lack insurance coverage or face financial challenges, as long as they meet specific eligibility criteria.
Tezspire (tezepelumab-ekko)
The Tezspire Together Co-pay Program can help eligible, commercially insured people get doses for as little as $0 or up to $100 off. Tezspire also has a patient assistance program where uninsured patients may receive their prescription for $0.
Affording Biologics on Medicare
People on Medicare are not eligible for drug company patient assistance programs. But people on Medicare Part D may be eligible for the Social Security Administration’s Extra Help (also known as Low-Income Subsidy, or “LIS”). This is a patient support program for people with low incomes. People eligible for Extra Help typically pay between $0 and $9 for their prescriptions.
Support from Nonprofit Organizations
Charitable organizations such as The Assistance Fund, Inc., Patient Advocate Foundation and The HealthWell Foundation are dedicated to offering financial support to patients with specific medical conditions, irrespective of their chosen treatment. People with commercial or public insurance, including those under Medicare and Medicaid, can reach out directly to these foundations for financial assistance.
