Question re insurance

@guinivere

My Medicare Advantage Plan covered Tymlos as a tier-5 script that fell under prescription drug coverage . . . in and out of the “gap” and ending as a very small co-pay by around July/August. As Evenity is injected in a doc’s office or clinic, the procedure code is different (sorry, I can’t remember the insurance terminology, but it falls under something like “medical services”) and is billed at about the same amount each of the 12 months, so I knew what to expect. Prolia may be billed the same way as Evenity as it is administered in a doc’s office.

You can call BC/BS and ask them what your co-pay would be if you have an advantage plan. The first six months of Tymlos, for me anyway, was every expensive - there are subsidies from other sources to assist if you qualify - I had a pharmacy team member just about in tears telling me how much my co-pay would be.

Bottom line is make the call to BC/BS and ask them what they estimate your costs will be; they should be able to give you some idea even if the amount changes due to the contract purchase price and what your insurance will cover. They may also be able to help to see if you qualify for any of the subsidies.

Best wishes to you as you continue through this process. Cheers!

@guinivere I suggest calling the phone number on the back of your Blue Cross/Blue Shield member card and ask your question. The person you speak to can then look up your particular plan and answer your questions about the cost of each of the medications and what your responsibility in co-pay would be. @beanieone provides a good suggestion of looking into the programs that you may be eligible for. Sometimes these subsidy programs are available through the drug company itself. You can also ask your pharmacist about subsidy programs because in my experience I've received good advice from my pharmacy on such programs.

beanieone,
I have regular Medicare in addition BCBS. Like you the first part of the year is pretty expensive until I got into the Catastrophic category. I think Prolia is very different.

Same here, @guinivere, Prolia, like Evenity, is administered in the doc’s office. Even though there is a script for both medications, they are coded and billed as two different Medicare “parts” (prescription drugs, i.e., Tymlos, vs medical services . . . our friends Prolia and Evenity) to insurance companies.

As an aside, it stands to reason that the assistance programs are income related and some don’t apply to those of us on Medicare. Prior to going through the process, ask about program guidelines - although I appreciated her willingness to help, my rep did not know much about the programs she was representing.

I hope everyone is cool and comfortable. Chill, y’all!

I am one who gives self injection of Evenity .

@kristie25

Wait, what!!?? You are the first person I've heard that from - my doc automatically set up in-office injections and I assumed (since Tymlos is a small automatic needle/dosage and Evenity is not) that there was no in-home injection protocol for Evenity. That might explain the difference between those of us who had the script for Evenity covered by Part D and those of us who didn't. Thanks for the correction and update. My apologies for misstating the info.

Cheers!

What I found was that Tymlos is a tier 2, which is pretty nice. Same with Prolia. At this point I think I will switch to Tymlos to start with & then in 2 years switch to Prolia which I can just stay on.

@kristie2 I don’t know of anyone here on Mayo Clinic Connect who self-administers Evenity injections. Do you reside in the U.S.? If you do reside in the U.S., Is Evenity covered by your health care insurance?

In my case Evenity is covered through my Part B Traditional Medicare because I go to an infusion center for my injections.

Yes, I live in Nevada and my endocrinologist office did not administer the injections and my insurance did not cover it being given at an infusion center . So ended up self administering. I have Medicare supplemental insurance.

What med are you using? Is it Prolia?