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Biologics Not Covered

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Ulcerative Colitis
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Posted 6/8/2021 7:26 AM (GMT -5)
I've been back and forth about starting biologics for about 6 years now. I've been able to keep things at bay through mesalamine, occasional corticosteroids, and diet manipulation. Never perfect but usually acceptable. Every once in a while things feel worse and I reconsider biologics.

Turns out, despite paying over $600/month for health insurance from the Marketplace my plan doesn't cover biologics. Well, it covers Humira at 50% which can still cost me $1000/month. I wanted to go on Entyvio which is not covered at all, even once I've hit my out of pocket maximum which is ludicrous to me. Remicade, shockingly, is also not covered.

Just wondering if people here have thoughts / tips if they've been in this situation. If there's some loophole I'm not aware of or something.


Thanks
Posted 6/8/2021 8:56 AM (GMT -5)
Humira has a savings card, you can go to their website to find out what they will pay. I used it years ago & paid very little. Perhaps this will make it more affordable for you.
Posted 6/8/2021 1:59 PM (GMT -5)
Both Remicade & Entyvio are not in my prescription plan but are covered under major medical. Your doctor needs to get them pre approved for the med and the infusion center. Both have co-pay assistance through the pharmaceutical companies. The way it works for me is that the infusion center bills everything to insurance. Insurance pays what they allow and then you turn in the rest of the cost of the med only to the co pay assistance program. Usually after my first infusion of the year I hit my max out of pocket. But most of that max out of pocket is paid by co pay assistance.

Confusing and weird, but it's the only benefit of being on biologics. I have an infusion in January and have to pay my portion ($5) after co pay assist. Then the rest of the year all medical is free since I hit my max oop.
Posted 6/10/2021 6:56 PM (GMT -5)
Most drug companies also have a “free” option for those who don’t qualify under an insurance program. You have to do some nosing around to find it (it’s different/separate from the copay program). I get my migraine medication that way and used to get my Apriso the same

I’d call entyvio manufacturer and see what assistance they can offer. I’ve found the companies to be really nice and helpful. Applications are income based but they aren’t allowed to dig into your financiers for verification
Posted 6/11/2021 8:50 AM (GMT -5)
The all have co-pay assistance programs. I've utilized these for Remicade, Humira, Entyvio, Stelara, and I recently signed up for Xeljanz's as well. They all have websites and a phone number you can call where a person helps you sign up and can answer questions and give you an estimate of what your co-pay will be. It's usually only $5 and sometimes it's free (Xeljanz for me). All you have to do to qualify for these programs is have commercial insurance (not something like Medicaid). They all have caps to what maximum amount these programs will pay per year so you'll want to look at that since your insurance only covers 50%. Maybe shop around for a different insurance plan. That sounds terrible for how much you pay.
Posted 6/11/2021 3:31 PM (GMT -5)

CCinPA said...
Both Remicade & Entyvio are not in my prescription plan but are covered under major medical. Your doctor needs to get them pre approved for the med and the infusion center. Both have co-pay assistance through the pharmaceutical companies. The way it works for me is that the infusion center bills everything to insurance. Insurance pays what they allow and then you turn in the rest of the cost of the med only to the co pay assistance program. Usually after my first infusion of the year I hit my max out of pocket. But most of that max out of pocket is paid by co pay assistance.

Confusing and weird, but it's the only benefit of being on biologics. I have an infusion in January and have to pay my portion ($5) after co pay assist. Then the rest of the year all medical is free since I hit my max oop.

Oh that's awesome, so even though co-pay assistance is paying for it, as far as your insurance is aware you paid your max out of pocket so now everything else is covered? Nice

Thank you all for the replies. Great to know I may have these options.

FlowersGal said...
Most drug companies also have a “free” option for those who don’t qualify under an insurance program. You have to do some nosing around to find it (it’s different/separate from the copay program). I get my migraine medication that way and used to get my Apriso the same

I’d call entyvio manufacturer and see what assistance they can offer. I’ve found the companies to be really nice and helpful. Applications are income based but they aren’t allowed to dig into your financiers for verification

Interesting, wasn't aware of the free option. So they can't verify and claim fraud or something?
Posted 6/11/2021 4:00 PM (GMT -5)

Sara14 said...
The all have co-pay assistance programs. I've utilized these for Remicade, Humira, Entyvio, Stelara, and I recently signed up for Xeljanz's as well. They all have websites and a phone number you can call where a person helps you sign up and can answer questions and give you an estimate of what your co-pay will be. It's usually only $5 and sometimes it's free (Xeljanz for me). All you have to do to qualify for these programs is have commercial insurance (not something like Medicaid). They all have caps to what maximum amount these programs will pay per year so you'll want to look at that since your insurance only covers 50%. Maybe shop around for a different insurance plan. That sounds terrible for how much you pay.


The Entyvio center told me they cover up to $20,000 for the year. Does anyone know how much a typical infusion costs? I was thinking this was my golden ticket but if each infusion is something crazy like $5k then that isn't super helpful :\

Edit: I just read each Entyvio infusion is $6700.....so I could only get 3 infusions worth?
Posted 6/11/2021 4:51 PM (GMT -5)
David -- you should check with your insurance and see if they cover Entyvio under your major med plan. If they do, once you meet your max out of pocket you won't have to worry about going over the limit for the co pay assistance program.

The way it worked for me:
The infusion center billed the cost of the med as well as the infusion to insurance
Insurance says how much they pay to the infusion center and then you are responsible for the rest
Send a copy of the EOB along with a J-code for the just the med portion that insurance didn't pay to the co pay assistance program.
Co pay assist pays all but $5.

Insurance doesn't care who pays the portion you are responsible for whether it's you or the co pay assist. They count the portion that you are responsible for as your out of pocket costs.

Your doctor's office should be able to help you with getting the pre authorizations you need for any biologic and should be able to tell you how it's covered under your plan.
Posted 6/11/2021 5:47 PM (GMT -5)

CCinPA said...
David -- you should check with your insurance and see if they cover Entyvio under your major med plan. If they do, once you meet your max out of pocket you won't have to worry about going over the limit for the co pay assistance program.

The way it worked for me:
The infusion center billed the cost of the med as well as the infusion to insurance
Insurance says how much they pay to the infusion center and then you are responsible for the rest
Send a copy of the EOB along with a J-code for the just the med portion that insurance didn't pay to the co pay assistance program.
Co pay assist pays all but $5.

Insurance doesn't care who pays the portion you are responsible for whether it's you or the co pay assist. They count the portion that you are responsible for as your out of pocket costs.

Your doctor's office should be able to help you with getting the pre authorizations you need for any biologic and should be able to tell you how it's covered under your plan.

OK thanks, I will a "major med plan", I've not heard of this. I did ask the insurance company though if, once I reach my out of pocket max, Entyvio would then be covered. They said no, because it is not covered by my insurance plan. I thought that was kind of ridiculous given it's supposed to be an out of pocket max but I will still ask about that major med plan.

And as you mentioned, I assume my GI doc will be somewhat familiar with helping people get these medications...hopefully.
Posted 6/11/2021 6:44 PM (GMT -5)
My entyvio infusions are billed at $16k each. Between Medicare and my supplemental, they allow $5-6k. It’s very expensive. Call entyvio (Takeda) and ask for options. They will be more knowledgeable
Posted 6/11/2021 10:34 PM (GMT -5)
Yeah, and they only cover the cost for the medicine. The infusion center costs are additional, so you should ask your insurance how much of that you cover. What a nightmare. Your insurance sucks. My Entyvio was $5 + infusion center cost of about $45.
Posted 6/12/2021 6:27 AM (GMT -5)
I mean the part of your insurance that covers doctor visits and hospitalizations -- your health plan, not your prescription plan. Not sure what kind of health insurance you are on, but a lot of plans keep prescription drugs drugs on a separate plan than the rest of your insurance. It will be covered the same way chemotherapy drugs are covered -- as part of the plan that covers hospitalizations -- not your prescription plan.

Talk to your doc -- they are used to dealing with insurance,
Posted 6/12/2021 2:02 PM (GMT -5)
I should have qualified my response — Medicare covers 80% of the 5-6k and my supplemental covers the remaining 20%, including the infusion cost. I pay $0, thank god. All under major medical — not prescription, because the drugs are administered in a dr/hospital setting.
Posted 6/14/2021 9:09 AM (GMT -5)
OK thanks, my insurance specifically told me it wasn't covered and to call Entyvio to ask for assistance. I have Blue Cross Blue Shield "Personal Choice" from the Marketplace because my employer's plan was abysmal. It was the best (and most expensive) option available in the Marketplace.

I will discuss more with my doctor. I'm still not 100% sure I'm going on a biologic, they will always scare me, but it's been 10 years with IBD and it certainly isn't getting better.
Posted 6/14/2021 12:58 PM (GMT -5)
I have BCBS through my employer. I know they have lots of plans, but if that was the best plan on the marketplace I still think they will cover it the same way they cover chemo drugs. Since it's not covered separately as a standalone medication, I'm not sure a CSR at BCBS would know whether it's covered. You'll know if your doc gets the pre authorization for it.

~fingers crossed~ Good luck!
Posted 6/14/2021 4:01 PM (GMT -5)
That's sad and scary if that's the best the marketplace has to offer. It's a total nightmare dealing with those BCBS customer service reps. They don't understand the medical thing that is being discussed here. I didn't either until it was explained to me here. Try explaining it to some of their reps and their heads spin. Good luck...
Posted 7/12/2021 5:05 PM (GMT -5)
Yes. If not on Medicare yet, contact Abbvie and get $5 co-pay card.

Once on Medicare you can apply for free Humira through Abbvie Patient Assistance Program. You have to fill out an application online and send then your 2-page 1040. A single with less than 77k gross income is eligible. You have to apply every year. I’ve been told they just ask if your insurance has changed and don’t scrutinize income but this is my first month on Medicare.
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