What is a biologic drug?

A biologic is a medication that is derived from a living organism. A biologic is often used to treat moderate to severe inflammatory conditions such as rheumatoid arthritis (RA). Common biologic drugs for the use of arthritis include Enbrel, Humira and Remicade.

The manufacturing process is complex, the logistics of transporting and maintaining supplies are expensive, and the total cost to the consumer can range from approximately $20,000 to $50,000 per year for one person.

While this cost may seem significant the use of a biologic drug can be life altering; improving a person’s quality of life substantially and potentially preventing disability or absenteeism from work.

Is a biologic drug right for you?

Choosing an appropriate biologic drug that is right for you can be difficult. If your RA symptoms do not improve by taking one or more disease-modifying anti-rheumatic drugs (DMARDs), your rheumatologist may recommend a biologic therapy. The Arthritis Research Centre of Canada is developing ANSWER-2, an online decision-making tool for people with RA who are considering a biologic therapy for their treatment. This decision aid will feature real life patient stories and evidence-based information tailored to the individual to help consider the pros and cons of the biologic treatment in a meaningful way. Testing of the ANSWER-2 prototype is expected to be completed by Winter 2014.

Stay tuned for updates on the ARC website and in future newsletters.

Are biologics covered by the provincial program or by extended health plans offered by employers?

Since the cost of biologic drugs is significant it is important to first ensure that it is the right option for you. If you and your rheumatologist agree that it is appropriate, there may be coverage available through your provincial program or your extended health plan offered by your employer (or perhaps through your spouse’s plan).  The following are recommended steps to assist you with determining what coverage you may have available to you:

Step 1:

Research if there may be coverage through your provincial program. Coverage for biologics varies from province to province. Your rheumatologist should have information with respect to what coverage is available in your jurisdiction and how to apply. You can also do your own review of the information on the provincial plan website.

Step 2:

If you have access to a health plan, either through your employer or your spouse’s coverage, contact the insurance company(ies) and ask what is eligible.  You should be prepared to provide your policy number and employee/certificate number when calling them. Due to the cost of biologic drugs, it’s important to understand what your insurance policy will cover. To ensure sustainability of drug plans, insurers have implemented various processes and provisions that may exist under your policy. The following are a few examples of these processes and protocols:

• Your insurer may require proof that less expensive drugs were tried first, but were not effective before they will consider approving coverage for a biologic – this is often referred to as ‘prior authorization’.
• If coverage is available through your province the insurer may also require you to provide proof that you have applied for provincial coverage.
• You may be required to purchase your biologic at a specific pharmacy where better pricing has been negotiated.
• Your insurer may require that you first try a lesser expensive biologic prior to having access to a more expensive brand.

Contacting your insurance providers in advance will help clarify the process you must follow to obtain approval for coverage and will hopefully reduce any frustration for you. The provisions are there to ensure drug plans remain sustainable over time and the coverage for biologics is there for people who really need it.

Note: If you do not have coverage through a provincial program or an employer plan, the manufacturer of the biologic drug may have a financial assistance program. Contact the drug manufacturer to learn more about any programs that may be available to you.