Understanding the Bimzelx List Price
Before considering the impact of insurance, it's helpful to understand the drug's starting price. The list price of BIMZELX is approximately $7,922.89 per 1 mL autoinjector or syringe. This is the price set by the manufacturer and is rarely the amount a patient with insurance will pay out-of-pocket. The difference between the list price and your final cost is determined by your specific insurance plan's coverage terms, including its formulary, copayment, coinsurance, and deductible requirements.
The Cost with Commercial Insurance
For those covered by private health insurance through an employer or a private individual policy, the final cost of Bimzelx is highly dependent on the plan's design. The manufacturer offers programs that can significantly reduce this financial burden.
BIMZELX Navigate® Savings Program
This program is a crucial resource for commercially insured patients. Eligible patients who have received approval for Bimzelx coverage from their insurance can pay as little as $5 per dose by utilizing the BIMZELX Navigate Savings Card. This copay assistance can help patients meet their out-of-pocket obligations for co-payments, coinsurance, and deductibles.
BIMZELX Navigate® Bridge Program
Insurance approval for a new biologic like Bimzelx often requires prior authorization and can involve delays or initial denials. For eligible commercially insured patients facing these issues, the Bimzelx Navigate Bridge program offers a temporary solution. It provides the medication for as little as $15 per dose for up to two years, or until the patient's commercial insurance approves coverage. To maintain eligibility, the patient's provider must submit an appeal if the prior authorization is initially denied.
Impact of Deductibles and Coinsurance
Without a savings card, your out-of-pocket cost is subject to your plan's specific benefits. Most plans have an annual deductible that you must meet before your insurance starts covering a larger portion of the cost. Once the deductible is met, you may be responsible for a coinsurance amount, which is a percentage of the drug's cost. The manufacturer states that the majority of commercially insured patients will pay between $0 and 26% of the drug cost every two months, based on their benefit design.
The Cost with Government-Funded Insurance
Government health plans like Medicare and Medicaid have different rules regarding drug costs and are generally not eligible for manufacturer copay savings cards.
Medicare Part D Coverage
For patients with Medicare Part D, the cost of Bimzelx is determined by their specific plan and which coverage phase they are in.
- Deductible phase: You may pay the full cost of the drug until you meet your plan's annual deductible.
- Initial Coverage phase: After meeting the deductible, you pay your plan's copay or coinsurance, and the plan covers the rest.
- Coverage Gap (Donut Hole): In this phase, there's a temporary limit on what Medicare will cover, and you may pay a higher amount for your drug.
- Catastrophic Coverage phase: After reaching this point, Medicare will cover most of the cost.
Some low-income Medicare patients may qualify for the federal Extra Help program, which significantly reduces out-of-pocket costs.
Medicaid Coverage
For most people on Medicaid, the out-of-pocket cost for drugs like Bimzelx is significantly lower. Copays may range from approximately $4.95 to $9.85 per month. In some states, copay requirements for prescriptions may be eliminated altogether. Eligibility and specific costs can vary by state.
Financial Assistance Beyond Manufacturer Programs
For those who are uninsured, underinsured, or ineligible for manufacturer copay cards, several independent organizations offer financial assistance. These programs have their own eligibility criteria based on income, insurance type, and diagnosis.
- Patient Access Network (PAN) Foundation: May provide assistance for copays and deductibles for Medicare patients and others who meet income and insurance criteria.
- HealthWell Foundation: Offers copay assistance for insured patients who meet specific criteria.
- Patient Advocate Foundation (PAF) Co-Pay Relief Program: Provides direct payment to help cover copayments, coinsurance, and deductibles for qualified patients.
Comparing Bimzelx Costs by Insurance Type
Here is a comparison of potential costs based on different insurance scenarios. Note: These are estimates based on available program information and patient costs are subject to change based on individual plan details.
| Insurance Type | Typical Patient Cost Range | Manufacturer Program Available | Additional Considerations |
|---|---|---|---|
| Commercial (with Savings Program) | $5 per dose | Yes (Navigate Savings Card) | Must meet program eligibility; prior authorization required |
| Commercial (without Savings Program) | $0 to 26% of drug cost every 2 months | N/A | Costs higher until deductible is met |
| Commercial (coverage pending) | $15 per dose (up to 2 years) | Yes (Navigate Bridge Program) | For delays/denials; prior authorization appeal required |
| Medicare (without Extra Help) | Variable; depends on coverage phase | No | Savings card not eligible; costs affected by deductible and donut hole |
| Medicare (with Extra Help) | $4.50 to $11.20 per prescription | No | Federal program, requires eligibility |
| Medicaid | $4.95 to $9.85 per month | No | Copay varies by state, some states have no copay |
How to Reduce Your Cost
Beyond enrolling in financial assistance programs, there are other strategies to explore for lowering your out-of-pocket expenses:
- Prior Authorization: Always ensure your doctor submits and receives prior authorization from your insurer before starting treatment. Skipping this step could leave you responsible for the full, high list price.
- 90-Day Supply: Ask your doctor or insurance provider if a 90-day supply is an option. If approved, it can lower the cost per dose and reduce trips to the pharmacy.
- Mail-Order Pharmacy: Consider using a mail-order pharmacy, which can sometimes provide cost savings and convenience. Some Medicare plans offer this option.
- Shop Around: Different pharmacies may charge different prices. Compare costs across pharmacies or through online tools like GoodRx.
- Contact Your Plan Directly: The most accurate information will come from your insurance provider, as they know the specifics of your plan's formulary, deductible, and out-of-pocket maximums.
Conclusion
While the sticker price of Bimzelx is substantial, your final out-of-pocket cost is not determined by this figure. The amount you ultimately pay is a result of a combination of factors, including your type of insurance coverage, your plan's specific details, your progress toward your deductible, and the availability of financial assistance. For commercially insured patients, manufacturer programs can bring the cost down to as little as $5 per dose. For those on government-funded plans, costs are dictated by different rules, but a range of independent assistance programs are available. The best path forward is to speak with your doctor and insurance provider, and to proactively explore all available savings programs to make this medication as affordable as possible.
For more information on the BIMZELX patient support programs, you can visit the manufacturer's website: BIMZELX Navigate.
