Biologics have revolutionized treatment for chronic diseases like severe asthma, eczema, rheumatoid arthritis, and inflammatory bowel disease. They offer targeted relief, slowing disease progression and improving quality of life. Yet, their high cost is a formidable obstacle for many patients. 

However there are ways to overcome these and other obstacles when it comes to patients who may be bio-hesitant, including providing proving information about smart insurance strategies, patient assistance programs, and cost-effective alternatives.

 

Insurance navigation and advocacy

 

Understanding insurance coverage for biologics can be daunting. Patients may face hurdles like prior authorizations, step therapy, or high out-of-pocket costs, which are made more complex by the prevalence of high-deductible health plans.

Persistence and meticulous record-keeping are key when dealing with insurance companies. Proactive communication, documenting all conversations, and utilizing appeals processes are vital. Seeking help from patient navigators or case managers can be invaluable in understanding coverage and requirements. Disease-specific support groups can also provide valuable insights and shared experiences in navigating similar challenges.

Prior authorization practice resources. AMA. May 18, 2023.

 

Healthcare providers play a crucial role as advocates, providing detailed clinical information, supporting appeals, and exploring alternative coverage options when necessary.

 

Patient Assistance Programs (PAPs)

 

Many pharmaceutical companies offer PAPs to help eligible patients access their medications at a reduced cost—or even for free. Eligibility criteria typically include income level, insurance status, and diagnosis. 

The application process for PAPs can be complex, but healthcare providers, social workers, and patient advocacy groups can provide guidance and support to navigate it successfully.  

 

Cost-effective alternatives

 

While biologics are often the preferred treatment, exploring cost-effective alternatives may be necessary. Biosimilars are highly similar versions of biologics with comparable safety and efficacy, often (though not always) available at a lower price.

Feng K, Russo M, Maini L, et al. Patient out-of-pocket costs for biologic drugs after biosimilar competition. JAMA Health Forum. 2024;5(3):e235429.

 

Traditional generic medications are not available for biologics due to their complex nature. Biosimilars can be a great option for patients facing financial constraints, though some individuals may respond better to the brand-name biologic.

 

Other strategies

 

• Co-pay assistance/coupon programs: These programs, often sponsored by pharmaceutical companies or non-profits, can help with out-of-pocket costs. However, Medicare patients often don't qualify for the pharmaceutical-based programs.

  Help Your Patients Access Biologic Treatments. National Psoriasis Foundation. 2024.

   

• State and hospital system assistance programs: Some states and hospital systems offer financial assistance programs for low-income individuals needing medications, including biologics.

• Clinical trials: Participation in clinical trials may provide access to investigational medications at no cost. However, physicians can be prepared to discuss potential risks and benefits, including the possibility of being in the placebo group, with their patients.

• Negotiating with pharmacies: In some cases, pharmacies may offer discounts or payment plans to help patients manage the cost of their medications.

Improving patient access to biologics is a shared responsibility. By exploring cost-effective options, utilizing patient assistance programs, skillfully navigating potential roadblocks with insurance companies, and advocating for patients' needs, everyone—HCPs, pharmaceutical companies, insurers, and patient advocacy groups—must work together to make these life-changing therapies more attainable and affordable for all.