The High List Price of Zymfentra
When Zymfentra, a subcutaneous (SC) formulation of infliximab, became commercially available in the U.S. in March 2024, its wholesale acquisition cost (WAC) was set at $6,181.08 for two shots over four weeks. This WAC, or list price, is the benchmark price set by the manufacturer, Celltrion, and is typically what insurers use as a basis for negotiation.
It's important to understand that this list price is almost never the amount a patient pays out-of-pocket. The final cost can differ dramatically based on a number of factors, including insurance coverage, pharmacy used, and available financial assistance. Retail prices at pharmacies can also vary, but generally reflect this high base cost without additional savings. For example, discount card providers have reported retail prices around $6,300 to $7,500 for a carton containing two pens or syringes.
Factors Influencing Your Zymfentra Cost
Your actual out-of-pocket expense for Zymfentra is a complex calculation involving several key factors. Since Zymfentra is a specialty biologic medication, it often falls under a different tier of prescription drug coverage than standard medications, which can lead to higher copayments or coinsurance.
Impact of Insurance
For most people, health insurance is the primary factor in determining the cost of Zymfentra. A patient's cost will depend on their specific insurance plan and where they are in their deductible and out-of-pocket maximums. Key insurance-related factors include:
- Formulary Placement: Whether Zymfentra is a preferred or non-preferred drug on your plan's formulary can dramatically change your copay or coinsurance amount.
- Deductible: Patients must meet their annual deductible before their insurance begins paying for a portion of the medication's cost.
- Prior Authorization: Most insurance plans require a prior authorization for Zymfentra, which means your doctor must submit documentation to prove the medication is medically necessary before the plan will cover it.
Medicare prescription drug plans (Part D) also affect the cost based on which coverage stage the beneficiary is in. For example, during the initial coverage phase, a patient may pay a copay. If they enter the 'donut hole' or coverage gap, their costs can temporarily increase before a catastrophic coverage phase begins, during which Medicare covers most costs.
Programs to Lower Your Zymfentra Price
Given the high cost, manufacturer and third-party programs are crucial for making Zymfentra affordable. Here are some of the most common options:
- Manufacturer Copay Program: For commercially insured patients, Celltrion offers the Celltrion CARES Co-Pay Program. Eligible patients may pay as little as $0 out-of-pocket per dose.
- Patient Assistance Program (PAP): The manufacturer also runs a patient assistance program through Celltrion CONNECT® for uninsured or underinsured individuals. This program may provide the medication for free to those who qualify based on eligibility criteria.
- Discount Cards: Services like SingleCare and GoodRx provide coupons and discounts that can lower the retail price. For those without insurance, these can offer significant savings compared to the pharmacy's list price.
- Non-Profit Foundations: Non-profit organizations focused on inflammatory bowel diseases (IBD) may offer financial assistance or grants to help with medication costs. Patients can research relevant foundations to see if they are eligible for additional support.
Zymfentra Cost Comparison
Zymfentra is a self-administered, subcutaneous form of infliximab, which distinguishes it from other infliximab products that are given as intravenous (IV) infusions in a medical clinic. This difference in administration affects not only convenience but also the total cost, as IV infusions involve additional facility and administration fees.
Here's a simplified comparison of cost considerations for different infliximab products. Note that these are approximations, and actual costs will vary based on individual circumstances.
| Feature | Zymfentra (infliximab-dyyb) | IV Infliximab Products (e.g., Inflectra) |
|---|---|---|
| Administration | Subcutaneous (at home) | Intravenous infusion (in clinic) |
| Drug Cost | High list price (~$6,181/4 weeks) | Lower biosimilar list price (~$1,100-$1,200/100mg vial), but dosing varies |
| Related Fees | Potentially lower; does not include infusion center costs | High; includes facility, administration, and medical professional fees |
| Insurance Coverage | Varies by plan, often requires prior authorization | Varies by plan, often covered under medical benefit |
| Patient Cost | Can be low (>$5/month) with manufacturer copay card for commercially insured | Can have high copays or coinsurance depending on plan and benefit design |
Conclusion: Managing the Cost
The high list price of Zymfentra can be a significant barrier for patients, but it is not the only factor in determining how much the medication costs. Insurance, manufacturer assistance programs, and discount cards can drastically reduce out-of-pocket expenses. By working closely with their healthcare provider and enrolling in available support programs like Celltrion CONNECT®, patients can navigate the financial challenges associated with high-cost biologic medications. It is critical for patients to explore all their options and understand their insurance benefits to ensure they can afford and access this important maintenance treatment for Crohn's disease and ulcerative colitis.
Visit the Celltrion CONNECT® Website to explore financial assistance options
