Biologics and the Bottom Line: Understanding Your Real Costs — and How to Manage Them

When you’re prescribed a biologic therapy, whether it’s an injection, infusion, or another advanced treatment, you may feel hopeful about managing your condition, and rightfully so.

Biologics are often game-changers for chronic illnesses, including rheumatoid arthritis, psoriasis, and inflammatory bowel disease, among others. However, alongside feeling hopeful, you may be concerned about one thing in particular: the cost.

Why Are Biologics So Expensive?

Biologics are not your typical medications. In addition to the research and development costs associated with these highly personalized therapies, complex and costly manufacturing processes are involved, given that they are made from living cells.

Additionally, because they often treat rare or severe conditions, companies may charge higher prices due to the smaller patient base and ongoing research investments.

In the U.S., biologics fall into the category of specialty drugs, often costing thousands of dollars per month.

Who Pays: Commercial Insurance vs. Medicare

With Commercial (Private) Insurance

If you have private coverage, your plan may pay the lion’s share, sometimes, but not always.

You’re still responsible for deductibles, copays, and co-insurance amounts. Be aware of copay accumulator or maximizer programs; these practices may allow manufacturer discounts or copay assistance to help pay for your medicine, but often don’t count toward your deductible or out-of-pocket maximum. That can leave you unexpectedly on the hook for full costs once assistance runs out.

With Medicare

Medicare divides coverage differently.

Part B typically covers biologics administered through a clinic or infusion center, such as IV treatments.

Part D covers biologics that you inject at home. However, each Part D plan is unique, and depending on your coverage tier, you may still have copays or need to meet a deductible first.

How Prior Authorizations Affect Access

Many biologics require prior authorization.

Meaning your doctor has to show your insurance company that the drug is medically necessary, often by submitting your medical history and trying other, less expensive meds first, a practice known as step therapy.

This process can delay access to your biologic if the insurer initially denies your request for coverage. But advocating for yourself and having your healthcare team appeal can make a difference.

To support your case, keep detailed notes, document prior treatments, and ask your doctor to submit a letter of medical necessity. Many patients are ultimately approved, but persistence is often required.

Support Options to Ease Your Costs

There are several practical ways you can manage your out-of-pocket expenses:

1. Copay Assistance & Patient Support Programs

Manufacturers often offer programs that help reduce your copays or even cover your treatment entirely, if you qualify.

However, these are typically available to individuals with private insurance, not government plans such as Medicare or Medicaid.

2. Explore Biosimilars

Biosimilars are highly similar versions of biologic drugs and often cost significantly less, and more insurers are now pushing biosimilars over biologics to help reduce costs.

Discuss with your doctor the option of switching to a biosimilar if it’s an option for your treatment.

3. Watch for Hidden Cost Barriers

Be cautious if your insurance plan uses copay accumulator or maximizer tactics; these can mask the true level of assistance and may increase your long-term costs.

4. Ask for Help While You Appeal

If your coverage is initially denied due to step therapy requirements or prior authorization delays, you or your healthcare provider can appeal the decision.

Some states have laws that require expedited handling of biologic appeals, and you may qualify for external review if internal appeals fail.

5. Look for Charitable Foundations

Some nonprofit organizations and disease-specific groups offer grants to help cover the costs of medication.

If a manufacturer’s program is unavailable or insufficient, these foundations may fill the gap.

You’re Not Alone, and Help Is Within Reach

No doubt, facing the high costs of biologic therapy can feel overwhelming, but please know you’re not alone.

Working with your healthcare team to understand the real cost of your biologic therapy, how different insurers cover them, and how to navigate prior authorizations or copay assistance gives you power.

You deserve access to the treatments that help you live well. Lean on your healthcare team, explore all financial support avenues, and don’t hesitate to ask your insurer and your doctor what you can do next to protect your health and your wallet.