Wait! Don’t give up so easily! There is patient assistance for copay costs for most biologics. Specifically, Janssen Carepath has a program for Stelara that lowers your copay to $5 if you have commercial insurance. You do not qualify if you have Medicare or Medicaid. I used these programs with Remicade and Inflectra before I went on Medicare.

https://www.stelarainfo.com/ul...BwE&gclsrc=aw.ds

Jan

It's only $5 with their copay assistance program. I'm on it.

Janssen Carepath has the same program for Remicade and I pay $5 per infusion now. The retail cost of one Remicade infusion is around $10,000.00, but I just pay the $5 copay after my deductible is shot (as I explained in another thread these copay assistance payments count towards your deductible with most insurers, and you only pay the difference (if any) between those payments on your first infusion, and your deductible. Making it very wise to buy a high deductible plan. In my case I had to pay only around $400 out of pocket on a $5000 deductible and same on a $6500 deductible with my prior health insurer).

Most good infusion facilities know how these copay assistance programs work and they ask you to send them the credit card that Janssen sends out. I thought it was automatic that you get something from Janssen once you start on one of these biologics, but maybe not.

No, not automatic. It depends on your insurance. I have Kaiser and they do not deal with outside discounts and do not handle those sorts of reimbursements. I had to apply to the program myself and had to pay Kaiser up front, then apply on my own and send in my EOB statements for every infusion. I was then reimbursed by Janssen directly. Once I reached my out of pocket maximum my Kaiser copay was $0, so no further reimbursements after that in that calendar year.

Once it was set up, it was easy. I could upload docs online, then they would send me a check.

Jan

I don’t qualify for $5

it amazes me!

I am surprised to learn this. If you have insurance through work or individual coverage, you should qualify. But note, this assistance only covers the portion of the cost for the drug (Stelara), not the other administration costs, such as facility fees, physician oversight, premeds, IV, etc.. $62K seems like a very high charge, but what do I know? I treat through an HMO.

Jan

@Jan Dollar posted:

I am surprised to learn this. If you have insurance through work or individual coverage, you should qualify. But note, this assistance only covers the portion of the cost for the drug (Stelara), not the other administration costs, such as facility fees, physician oversight, premeds, IV, etc.. $62K seems like a very high charge, but what do I know? I treat through an HMO.

Jan

I have the type of insurance that doesn’t qualify. It’s just shocking to me, if I had private insurance I’d pay $5. And the hospital can charge $62,000 for this. Something is definitely wrong with our healthcare system.

Oh, so you have government funded insurance. I would not worry about how much they charge because that big number is not what anybody pays. It all gets carved down through fee schedules and whatnot. It is a stupid game actually.

Jan

@Jan Dollar posted:

Oh, so you have government funded insurance. I would not worry about how much they charge because that big number is not what anybody pays. It all gets carved down through fee schedules and whatnot. It is a stupid game actually.

Jan

I understand, it’s still outrageous. And the amount they want me to pay is also outrageous. Unless the hospital can give me  a discount on my portion, it’s no go for me.

Maybe try a different infusion center? You certainly do not need to be at a hospital for your infusion.

Jan

@Jan Dollar posted:

Maybe try a different infusion center? You certainly do not need to be at a hospital for your infusion.

Jan

It’s the doctors office which is NYU.  They didn’t give me a choice of choosing an infusion center.
I’ve been up in the air about taking this medicine with all the side effects it has, the expensive co-pay made my decision for me.
maybe there’s something else out there that may work and is a little cheaper 🤞

What would be cheaper is an injection you give yourself at home. That would be Humira, Amjevita and Syltezo (Humira biosimilar), Simponi, and Cimzia.

Stelara is only infused IV with the first treatment. The rest are injections.

But, if you are really adverse to the potential side effects of these drugs, you are better off avoiding them. You’d probably be waiting for the next shoe to drop all the time. For me, the risks of NOT getting my pouchitis under control was much more concerning. It is all about what risks you can live with, because every choice has risks. I hope you find your solution.

And yes, I 100% agree that the state of our health care system is a mess. We spend the most money in the world, but do not have as good of outcomes as countries that spend a fraction.

Jan

Thanks for your advice Jan, I really do appreciate it 😊

Stelara has a good safety profile compared to the other biologics. Sorry your insurance doesnt qualify for the program. If it makes you feel better, it has done absolutely nothing to help my UC.

When I was taking humira. It was $1700 per shot.

Two in a box.

Remicade. When I was taking it was $7000 per infusion.

I had insurance and had to pay the majot medical deduction.

Humira is up to almost $4000 per shot now. I don't use any of it anymore. But you can look up cost of biological meds.

Now you know why and how they pay for all these wonderful commercials you see on TV.

P. S.

Humira never worked. But I tried it for a long time along with another injectable after.

Remicade worked almost too well. Lol. Until it didn't.