Understanding the Cost of ZILRETTA
ZILRETTA (triamcinolone acetonide extended-release injectable suspension) is a medication used to treat knee pain associated with osteoarthritis. Unlike standard steroid injections, ZILRETTA is designed to release medication slowly over approximately three months. The total cost of a ZILRETTA injection is not a single, fixed price; it is influenced by several factors, including your insurance plan, where the injection is administered, and your access to manufacturer support programs.
The components of your ZILRETTA bill
The total cost of a ZILRETTA injection is typically composed of two main elements:
- The drug cost: This is the price of the ZILRETTA vial itself. Various pharmacy discount programs list the price for a 32 mg vial in the range of $600 to $700 or more, though this price can vary by pharmacy and location.
- The administration fee: This is the charge for the medical procedure itself, covering the cost of the healthcare professional's time and the use of the facility. Since ZILRETTA must be administered by a doctor, this fee can be substantial. For example, MDsave listed an in-office ZILRETTA injection procedure for $1,265.
Uninsured vs. Insured Costs
Your insurance status is the most significant factor determining your out-of-pocket cost for a ZILRETTA injection.
Cost without insurance
For patients who are uninsured or those with high-deductible plans who have not met their deductible, the full cost of the procedure can be substantial. As mentioned, the total cost could exceed $1,200. The final price is a combination of the drug's retail price and the provider's fee. Without insurance negotiation, you are responsible for the entire amount. However, there are options to reduce this cost, such as using pharmacy discount cards or enrolling in manufacturer assistance programs.
Cost with insurance
For patients with health insurance, the billing and payment process is different. ZILRETTA is a provider-administered product, meaning it is typically covered under the medical benefit of a health plan, not the pharmacy benefit. This is often referred to as a "buy and bill" scenario, where the doctor's office purchases the medication and bills your insurance for the drug and the administration.
- Original Medicare Part B: This plan covers medically necessary, physician-administered injectable drugs like ZILRETTA. Once you meet your Part B deductible, Medicare pays 80% of the Medicare-approved amount, leaving you responsible for the remaining 20%.
- Commercial insurance: Coverage and cost-sharing will vary widely depending on your specific plan. Your out-of-pocket costs will be influenced by your deductible, coinsurance, and copayments.
- Medicare Advantage (Part C): These plans are required to cover everything Original Medicare covers, but they may have different cost-sharing rules. The manufacturer offers support for these patients through the FlexForward program.
Saving Money on ZILRETTA
Several programs and strategies can help reduce the financial burden of a ZILRETTA injection:
- FlexForward® Program: Offered by the manufacturer (Pacira BioSciences), this program provides comprehensive access support for patients with commercial and Medicare Advantage plans. A dedicated case manager can help investigate benefits, assist with prior authorizations, and provide coding and billing support to ensure proper reimbursement.
- ZILRETTA Copay Assistance Program: This program can help eligible commercially insured patients save money on their out-of-pocket costs. It is not available for patients enrolled in government-funded programs like Medicare or Medicaid.
- Pharmacy Discount Cards: Third-party services like Drugs.com, GoodRx, and SingleCare offer discount cards that can reduce the cash price of the ZILRETTA vial, though the discount amount can vary.
- Patient Assistance Programs (PAPs): These programs, often sponsored by pharmaceutical companies, may offer free or deeply discounted medication to low-income, uninsured, or under-insured individuals who meet specific criteria.
ZILRETTA vs. Alternatives: A Cost Comparison
To put ZILRETTA's price into context, it's helpful to compare it with other common knee osteoarthritis treatments. The cost-effectiveness of a treatment involves both its price and its long-term benefits.
| Treatment | Estimated Cost (General Range) | Duration of Effect | Notes |
|---|---|---|---|
| ZILRETTA | $600-$700 (drug vial), >$1,200 (procedure) | Up to 3 months | Extended-release formula for longer pain relief |
| Conventional Corticosteroid (e.g., standard triamcinolone) | Lower per injection | Shorter than ZILRETTA | Shorter pain relief |
| Hyaluronic Acid (HA) Injections (e.g., "gel shots") | $1,500-$3,500 for a series of injections (depending on insurance) | Up to 6 months per series | May require multiple injections in a series |
| Oral NSAIDs (e.g., ibuprofen) | Lower | Short-term | Over-the-counter and prescription options, but may not be effective for severe pain |
It is important to discuss all options with your doctor to find the most appropriate treatment for your specific condition and financial situation.
Conclusion
While the sticker price for a ZILRETTA injection can appear high, the final cost to the patient depends on a variety of factors. Insurance coverage, especially Medicare Part B, significantly reduces the out-of-pocket expense for many individuals. For those without insurance, or with high deductibles, manufacturer programs like FlexForward and the Copay Assistance Program are designed to help make treatment more accessible and affordable. It is crucial to work with your healthcare provider and insurance company to understand your coverage and explore all potential savings opportunities before treatment.
FlexForward® Program | ZILRETTA® Access Support
Disclaimer
The information provided in this article is for informational purposes only and does not constitute medical advice. The cost estimates are subject to change and depend on specific circumstances. Always consult with a healthcare professional to determine the appropriate course of treatment and your final cost.
