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Does Blue Cross Blue Shield cover Remicade?

BCBS plans may cover Remicade for FDA-approved uses, but they may require step therapy or prior authorization
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By | Oct. 15, 2024 Medically reviewed by Karen Berger, Pharm.D.
A health insurance card and a stethoscope: Does Blue Cross Blue Shield cover Remicade?

Key takeaways

  • Remicade is a biologic that belongs to a class of drugs called TNF blockers. It’s typically prescribed to treat rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis, and plaque psoriasis.

  • Some Blue Cross Blue Shield insurance and Medicare plans may cover Remicade. But some might require prior authorization, and how much they’ll cover depends on the specific plan.

  • To see if your BCBS plan covers Remicade, check your plan’s formulary (list of covered drugs), which you can typically find on the BCBS website or by calling your plan’s member services phone number.

  • Aside from insurance, considering biosimilar options, looking into patient assistance programs, and comparing prices are other ways to save on Remicade.

In this article:

Whether fighting infections, healing the body, or protecting it from germs, our immune systems have a lot of responsibility. But they can sometimes overreact, causing inflammatory diseases like rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, ulcerative colitis, and plaque psoriasis. Remicade (infliximab) is a tumor necrosis factor (TNF) blocker that’s approved to treat these conditions. But its effectiveness and versatility come at a price that leaves many patients hoping for health insurance coverage.

If you have a Blue Cross Blue Shield health plan, it might cover Remicade. But not all plans do, and some have restrictions and other requirements. We’ve got details on all that and more below.

Does Blue Cross Blue Shield cover Remicade?

Mohamed Noureldin, MD, gastroenterologist and founder of Scribe Medica, says Blue Cross Blue Shield (BCBS) plans often cover Remicade. However, not every BCBS policy provides coverage. It depends on your plan and the condition you’re treating.

The Blue Cross and Blue Shield Association doesn’t just have many different plans; it has many different companies. Most states have their own independent licensees of the Blue Cross, and each one has its own range of plans. While many will cover Remicade, these plans vary in how and when they’ll cover it.

If your private insurance covers Remicade, there might be some caveats involved. Specifically, it might have prior authorization requirements. Before issuing coverage, the insurance provider typically wants to confirm that Remicade is medically necessary for you and that you’re using it to treat a condition the Food and Drug Administration (FDA) has approved it to treat. “The requirement in my field of gastroenterology is a diagnosis of ulcerative colitis or Crohn’s disease,” Dr. Noureldin says.

In some cases, however, it might mean your healthcare provider needs to submit documentation of symptoms, specialist visits, or other information to BCBS. In others, you might need to try other medications first, which is a process called step therapy.

If you have a BCBS Medicare plan, it might cover Remicade under Part B since it is administered intravenously (through a vein) by a healthcare provider in an outpatient setting. You’ll be responsible for your Part B deductible, copays, and coinsurance. After you meet your deductible, you’ll typically be responsible for 20% of the Medicare-approved amount for Remicade, but the total amount can change as the drug’s price changes. 

What about Remicade biosimilars?

Remicade is a biologic drug, which means it’s created out of human, animal, or microorganism cells rather than dead or synthetic substances. Biosimilar drugs are extremely similar (although not exact replicas) to their biologic counterparts in the same way that generic drugs are similar to their brand-name counterparts. For example, Dr. Noureldin says, “Inflectra is an equally good alternative for treatment of ulcerative colitis or Crohn’s disease.” These drugs work the same way, and like generic drugs, they’re often cheaper than their reference medications, so some insurance providers might prefer them over brand-name biologics.

If your BCBS plan lists Remicade as a nonpreferred drug, it might provide better coverage for a Remicade biosimilar like Inflectra, Avsola, or Renflexis. You’d essentially be getting the same drug, but for significantly less money.

How much does Remicade cost?

Developing biologic drugs is an expensive and time-consuming process, so they can be pricier than other drugs, and Remicade is no exception. Since healthcare providers determine the dosage based on weight and administer it in the office, it’s difficult to pinpoint a specific price, but without insurance, it typically costs around $4,000–$7,000 every eight weeks.

Fortunately, insurance coverage, patient assistance programs, and other savings options can help people avoid paying that full out-of-pocket cost.

How much does Remicade cost with Blue Cross Blue Shield?

Even if your BCBS plan covers Remicade, that doesn’t necessarily mean you’ll get your medication for free. And the out-of-pocket costs you end up paying depend on your particular plan’s details.

Every health insurance plan has a formulary (a list of drugs covered by a plan) that shows its cost-sharing policies for every covered medication. These policies determine how much of the price the company will cover and how much the patient has to pay out of pocket. The patient’s portion usually takes the form of coinsurance, which is the percentage of drug costs you have to pay after meeting your deductible, or copays, which are set amounts you pay when you receive a medication or medical service.

Insurance providers organize covered drugs into tiers. In most cases, lower-tier drugs have fewer out-of-pocket costs, while higher-tier drugs come with higher copays and coinsurance. The number of tiers can vary by plan, but tier 1 is typically reserved for generic drugs, while brand-name and specialty drugs occupy the higher tiers. As a specialty drug—one that requires special handling or administration—Remicade is usually in one of the highest tiers.

How to check whether your Blue Cross Blue Shield plan covers Remicade 

Everything you need to know is in your plan’s formulary, and you can typically find the formulary on your BCBS licensee’s website. For example, if you have a plan from Blue Cross Blue Shield of Texas, you can go to its website and click the “Prescription Drugs” tab, then select “Prescription Drug Lists.” From there, just find the list for your plan and scroll down until you find Remicade.

Not every BCBS website has a Prescription Drugs tab. Some keep their formularies in their “Resources” section instead. Or, you can search for “Blue Cross Blue Shield formularies [state name]” on Google. You can also call your BCBS company directly to get the information from a customer service representative.

How to save on Remicade

Some people might not have insurance coverage for Remicade. Others might have coverage, but not as much as they’d like. Either way, there are other ways to make Remicade more affordable. They include:

  • Remicade coupons: It’s free to sign up for a SingleCare discount card, which offers savings on thousands of over-the-counter and prescription drugs. However, they only apply for drugs you get from the pharmacy. Most people get Remicade infusions as an in-office treatment, but if you get it from a specialty pharmacy, you can potentially take advantage of SingleCare discounts.
  • Alternative medications: Some biologic Remicade alternatives include Cimzia, Humira (adalimumab), Rituxan, Actemra, and Enbrel. However, not all of these drugs have the same FDA-approved uses, so the condition being treated will be an important factor in determining which medicines are appropriate. Also, these biologics might also be fairly expensive. Some nonbiologic options include Trexall (methotrexate), Arava (leflunomide), Azulfidine (sulfasalazine), and Azasan (azathioprine). Your healthcare provider will let you know which medications might work best for your specific condition.

RELATED: Remicade vs. Humira │ Avsola vs. Remicade

  • The Janssen CarePath Savings Program: Remicade’s manufacturer, Janssen Biotech, Inc., offers a program in which eligible patients can pay just $5 per infusion. To qualify, you must have private or employer-sponsored insurance that covers some out-of-pocket costs for Remicade. You can’t be enrolled in Medicare, Medicaid, or any other government prescription assistance programs.
  • Government assistance programs: Some Medicare beneficiaries may be eligible for Medicaid as well as a program called Extra Help, which assists individuals in paying for their prescription medications. Each state has its own Medicaid procedures, but qualifying applicants typically have to meet certain income requirements.
  • Asking your healthcare provider: They’re well-versed in your specific condition and medical history, so they can let you know about other, less-expensive treatment options that might work. They also might know if you’re a good fit for any assistance programs.

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