Tymlos - how does ANYONE on Medicare pay for this drug?

Hi @jclang, welcome. I moved your post to the new Osteoporosis & Bone Health support group here: https://connect.mayoclinic.org/group/osteoporosis/

I think you'll appreciate reading this very helpful post that @artscaping wrote to @amli65 regarding coverage for osteoporosis medication. While her post is specific to Evenity, I think some of the tips are transferable to your situation. See her comment here: https://connect.mayoclinic.org/comment/749893/

Fellow members @betterhealth @windyshores @contentandwell @psprice77 @csday @rubyz may also have some input about Medicare and affordability for you.

Jclang, you might also be interested in this related discussion:
- Forteo vs. Tymlos: Which did you choose? https://connect.mayoclinic.org/group/osteoporosis/

Hi, @jclang
Welcome to Connect.
I am on Medicare and on Tymlos. You are right, there is little help for those of us who are on Medicare unless your income is below a certain level. I had been told the level was somewhere in the $50,000+ range, not $13,000. Are you sure $13,000 is not a quarterly income?

We did not fall under the income limit so we discussed the cost and decided together that it was a sacrifice worth making for us. I realize though that not everyone is in that position.

There are two other medications that do build bone, Forteo, and Evenity. I don't know much about Evenity but I believe that it does build bone and is not a bisphosphonate.
Forteo is beyond the time when generics can be made to be used instead of a brand name so it might be available for less money.

The other option is Prolia (Denosumab). Here is an article about it vs bisphosphonates:
https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-finding-the-right-osteoporosis-medication/
and an article about Prolia:
https://www.goodrx.com/prolia/osteoporosis-injection-prolia
I hope you find a medication that will help your osteoporosis, be affordable for you, and not have difficult side effects.
JK

It is truly despicable. I'm in the same position with Forteo - $1920 a month until I reach the $8000 cap. Apparently the cap will be lower next year, but I don't know by how much.

I believe the cap for 2025 will be $2500. But check me on this.

I’m on Medicare with a plan D prescription program and receive my Tymlos through CVS specialty pharmacy. Since I don’t meet the income limit for assistance I pay full price. It was about $800 for January and February. Not sure of the price for this month yet but am in the coverage gap. The out of pocket is about $8k. I too am fortunate enough to be able to afford this essential (for me) medication. I certainly hope that greater strides are made towards reducing medication costs for those over 65.

I have been using Tymlos since 9/2022. I did not have any co-pay. Radius Labs paid my copay. I was told that that monthly copay was #350.00 However, 1/2024, my meds were subjected to Medicare Part D and I have a monthly copay of $150.00. I was able to switch back to my old insurance for meds and keeping my fingers crossed where Radius Lab would cover my copay next month and beyond.

According to a paper produced by the Kaiser Family Foundation, the $8000 you reference as a cap in 2024 is not simply out of your pocket but a combination of out of pocket AND something related to the drug manufacturer.

Here is the exact quote:

"In 2024, the catastrophic threshold will be set at $8,000. This amount includes what Part D enrollees spend out of pocket plus the value of the manufacturer price discount on brands in the coverage gap phase. At this amount, Part D enrollees who take only brand-name drugs in 2024 will have spent about $3,300 out of their own pockets and will then face no additional costs for their medications."

The entire Kaiser issue paper can be accessed here. https://www.kff.org/medicare/issue-brief/changes-to-medicare-part-d-in-2024-and-2025-under-the-inflation-reduction-act-and-how-enrollees-will-benefit/

I do not pretend to understand this but if I was looking at needing to have very pricey meds, I would study this 2024 change very carefully and try to get a complete understanding.

This is what I found (Inflation Reduction legislation):
~~~~~~~
Starting in 2025, Medicare Part D will introduce significant changes to benefit enrollees. Here’s what you need to know:

Out-of-Pocket Cap: Beginning in 2025, Part D enrollees’ out-of-pocket drug costs will be capped at $2,000. This means that once you reach this limit, you won’t have to pay any more out-of-pocket expenses for your prescription drugs during that year.
Indexing: The $2,000 cap will be indexed to rise each year after 2025 based on the growth rate in per capita drug spending3. For example, if Medicare spends 5% more in a given year, the cap for the following year would be 5% higher (e.g., $2,100).
Payment Flexibility: Additionally, you’ll have the option to spread out your out-of-pocket costs over the plan year by paying them in monthly amounts, rather than all at once when they occur2.
These changes aim to provide relief to Medicare beneficiaries and make prescription drug costs more manageable. Remember to stay informed about any updates and consult with your healthcare provider for personalized guidance.

Do not think there is much confusion about what is expected to happen in 2025 with Part D and out of pocket limits.

The question has to do with 2024....which is quite confusing over how the $8000 threshold is calculated.

You do not cite your source....does it address what the Inflation Reduction legislature does for Part D in 2024?

I’m also ineligible for Tymolos assistance. I changed Part D insurers and am awaiting approval and cost for this drug.
It is so unfair that both Tymolos and Forteo offer discount cards to those with commercial insurance but not to those with govt insurance. We also pay for our insurance even though it’s thru the govt.