These barriers may prevent patients from accessing effective treatment—here's how to help

By Kara Wada, MD | Fact-checked by Barbara Bekiesz
Published September 26, 2024

Key Takeaways

  • Biologics have greatly improved the management of chronic diseases like severe asthma and rheumatoid arthritis by providing targeted treatment and enhancing quality of life. However, their high cost remains a significant barrier for many patients.

  • Successfully accessing biologics often involves overcoming insurance-related challenges such as prior authorizations and high out-of-pocket costs.

  • Improving patient access to biologics requires a collaborative approach among healthcare providers, pharmaceutical companies, insurers, and patient advocacy groups, utilizing strategies related to insurance navigation and patient assistance programs, while exploring alternative treatment options.

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. 

But 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, 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.[]

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.[]

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.[]

  • 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.

What this means for you

Biologics have transformed the treatment of asthma and other chronic diseases by offering targeted relief and improving quality of life, but their high cost can be a significant barrier for many patients. To address this, strategies such as utilizing patient assistance programs, exploring cost-effective biosimilars, navigating insurance complexities, and seeking help from healthcare providers and support groups are crucial. Collaborative efforts among all members of the care team are essential to enhance accessibility and affordability of these life-changing therapies.

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