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How to appeal prior authorization denial for Tymlos?
@mayblin suggested I start a new discussion since I wasn’t sure where to post this.
I just received a denial for prior authorization for Tymlos saying the medicine can only be approved if the patient has a diagnosis of postmenopausal women with osteoporosis (my hip is -3.8) at high risk of fracture. I fractured my femoral neck of hip and my wrist 5 months ago.
Unfortunately my Dexa says 10 year fracture risk not reported because some t-score for spine total or hip total or femoral neck at or below -2.5. My spine is -3.1 and my femoral neck is -2.4.
I was shocked by the denial. Should I first talk to my doctor on how to appeal this? Get a copy on the info doctor sent in? Any advice would be appreciated. Thanks so much.
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@mayblin My understanding is that the appeal comes from the doctor. Others will know better. I hope you can get it. "Health care" is a misnomer.
According to my doc, my DEXA scores weren’t bad enough to really warrant prescribing Tymlos or Evenity but four compression fractures made the difference to the insurance company; perhaps vertebral fractures are more readily treated with T or E because of the “spine-building” claims. I would think your T-scores and your recent break would qualify you for one of these meds. My doc took care of the paperwork in both cases - I have been on both T and (now) E - so I would suggest starting with your healthcare pro. Wishing you the best!
Thank you for the reply. Your experience with the process will help others as well! I am gathering a lot of paperwork to give to my doctor. Both @mayblin and @awfultruth have given me studies that indicate an anabolic is best so hopefully the appeal will be successful.
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1 ReactionMy bone density was horrible. -4.7 in my spine and the insurance initially denied my prescription. They wanted me to start on Fosamax which would have done nothing for me. My doctor appealed my insurance and advised I had to be on a bone building medication. They finally put it thru. And I’m glad they did. I’ve been on Tymlos for almost 2 years and my spine numbers have improved by 11%. Good luck!
I’m so happy you have a good doctor that knew how to appeal for you and get you on the right meds! It’s amazing that an appeal was even necessary with a score like that. Congratulations on the improvement! What will you use to lock in the gains?
Good morning. I go off Tymlos in June and am concerned about what to do to keep my gains. As of yesterday, my cardiologist, who is very educated in bioidentical hormones has suggested them since I’m extremely lacking. I’m considering them as an alternative to another osteo med. Praying they will keep my bone gains while helping improve the typical issues women deal with when having a complete hysterectomy and lack of hormones. I’m going to give that a try and then reevaluate with tests after 6 months. My rheumatologist is not going to be happy because she wants me on another med but after 2 years of injecting myself, I’d like a break. The options are a bit unsettling. It’s not an easy journey for us. Hope you will find an option that works for you. 🌹