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@rjd, When teriparatide was prescribed, the pharmacy called me to make sure I understood the cost. I didn't!!! so I called Medicare and was referred to my supplemental. My supplemental referred me to my Part D prescription plan and I was told $1927/month was the copay. I am not eligible for any financial assistance. I saw a second MD who prescribed Tymlos which is even more expensive and not included in my Part D formulary. I saw a third MD and he prescribed Evenity. I haven't made any decisions about medication and was surprised that he contacted the infusion center without further conversation - I was waiting for the results of the CTX and P1NP. I called the infusion center on Friday and they told me they couldn't tell me if Evenity was covered unless I had an appointment so I made an appointment and hope to hear back from them this week. I don't think I can take Evenity due to a blood clot DX in my 20s, but wanted to play this out pending further conversation with the doctor.
I forgot that Evenity is different (thanks @susanfalcon52) b/c it is given at an infusion center so I'm sure I'm wrong about that one and have to wonder why the my Part D prescription plan and the infusion center didn't tell me that. Based on what @windyshores wrote, I will call Medicare and double check on Tymlos. Nothing about this diagnosis is easy.
Replies to "@rjd, When teriparatide was prescribed, the pharmacy called me to make sure I understood the cost...."
I have traditional Medicare and a plan D prescription program. I’m on Tymlos and don’t qualify for financial assistance. My medication comes from CVS specialty pharmacy. The cost was quoted about $1200.
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It is my understanding that many folks receive an Evenity injection in their doctor's office, not at an infusion center. I had one of my Prolia shots at an infusion center and the other one in my doctor's office.
I think the difference between processing and paying for Forteo/Tymlos and Evenity likely hinges on whether a medication is self-administered at home or administered in a clinical setting.
If at home, then you should look to your Medicare Part D plan.....what is the deductible and copay, is the drug on the formulary (apparently Tymlos is not on your Plan's formulary) and if it is not on the formulary, whether you should ask for an exception. Your doctor will need to be involved in trying to get an exception.
If the medication is given in a clinical setting, then the Medicare B process is used. This means Medicare usually pays 80% and you pay 20%. Then you look to your Medicare Supplement Plan or your Medicare Advantage plan for applicable deductibles and copays.
It seems most supplement plans pick up your entire share of the cost of Evenity because it is a Medicare B medication. The supplement plans do not cover Medicare Part D drugs for which you have a separate Plan.
I am hoping that if my understanding about Medicare B drugs and Medicare D drugs is incorrect, someone will set me straight.
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