1. < Osteoporosis & Bone Health

Change in commercial insurance carrier in new year

Posted by babbsjoy @babbsjoy, Dec 6 9:15am

I have been on Tymlos for about three months, and want to be able to continue with no interruption. Our company is changing insurance carriers for 2025, and I have concerns over approval and continuity with the new carrier. (Good news is the new to us company uses the same specialty pharmacy as our current carrier.). I do not yet have an ID card for the new carrier. Does anyone have experience with this situation, and getting the ball rolling for what initially was a lengthy approval process? (And I am really concerned that except I have been on the med already for over three months, I may not fit this company’s parameters for it—while I did under my old company’s guidelines—so it may be a long process….). Thx for any tips….

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Mentor
Sue, Volunteer Mentor | @sueinmn | Dec 6 2:06pm

@babbsjoy Congratulations on being proactive in managing your care, insurance changes often carry unhappy surprises.

First, if at all possible, get a refill of your Tymlos prescription to tide you over while negotiating with the new company! We had this issue last year and nearly ran out of one crucial medication.

Second, do not assume that because the new company uses the same pharmacy that they use the same formulary & the same rules.

Your next steps are-
Get a copy of the new insurance plan Drug Formulary (list of covered drugs) and the list of codes that indicate what actions are required before the will fill your prescription - prior approval, what the standards are for approval, etc.
Determine if the specialty pharmacy fills orders for this drug under the new plan (we found out that it is not always the case), otherwise you may need to find a new supplier.
Finally, get a copy of the appeals process for any denials in writing - with the contracted timelines for response.

We have been under a new pharmacy plan this year with my long-time insurer. The new plan not only used the same pharmacies, it had exactly the same Pharmacy Benefit Manager.
Yet they not only required new Prior Approvals for medications we were already using, but also denied those approvals and I had to appeal.
To add insult to injury, they stopped supplying said medications through their Mail Order, but failed to notify us that they did it, filling was delayed by weeks as we had to find a local supplier and pay a higher price.
Just when I thought I had seen everything, the real surprise came yesterday, when they refused a medication I have used for over 10 years, and said I had to go back and repeat the "step therapy" to prove I need it - and it is a generic drug!

I hope you have smoother sailing!

REPLY
1 reply
annie208 | @annie208 | Dec 7 5:28pm

I have a bit of experience assisting family members with this type of change (and in getting their pricey medications continued). I'd be happy to process with you through DMs once you find a few things out.

@sueinmn gave you the most important advice and that is to get your new plan's specific formulary. Do people talk to your HR department a lot about insurance? If so yours is probably a company sponsored plan (even if it's Blue Cross or some other familiar brand, it may be very specific to your company and your company may have called the shots on what it does and doesn't cover).

If your new drug formulary doesn't cover Tymlos, the insurance/pharmaceutical policy that you'll need to refer to and stand on as you advocate for yourself is "continuity of therapy" (COT). If you can let me know the name of your plan I can google and try to find PDF(s), etc. on their COT policy. Most state that if you have been on a medication for at least 90 days, your provider can arrange COT for you by filling out that form, which is a lot like a Prior Authorization request but is usually labeled a "Formulary Exception" request for reasons of COT.

You are smart to figure out your new plan's policies ahead of time so that you can get your ducks in a row and hit the ground injecting in January :-)!

REPLY
1 reply
babbsjoy | @babbsjoy | Dec 8 9:15am
In reply to @annie208 "I have a bit of experience assisting family members with this type of change (and in..." + (show)
@annie208

I have a bit of experience assisting family members with this type of change (and in getting their pricey medications continued). I'd be happy to process with you through DMs once you find a few things out.

@sueinmn gave you the most important advice and that is to get your new plan's specific formulary. Do people talk to your HR department a lot about insurance? If so yours is probably a company sponsored plan (even if it's Blue Cross or some other familiar brand, it may be very specific to your company and your company may have called the shots on what it does and doesn't cover).

If your new drug formulary doesn't cover Tymlos, the insurance/pharmaceutical policy that you'll need to refer to and stand on as you advocate for yourself is "continuity of therapy" (COT). If you can let me know the name of your plan I can google and try to find PDF(s), etc. on their COT policy. Most state that if you have been on a medication for at least 90 days, your provider can arrange COT for you by filling out that form, which is a lot like a Prior Authorization request but is usually labeled a "Formulary Exception" request for reasons of COT.

You are smart to figure out your new plan's policies ahead of time so that you can get your ducks in a row and hit the ground injecting in January :-)!

Jump to this post

@annie208
Thank you for your kindness and for being so informative. It appears that our new insurance (through my husbands employer) does approve and provide for Tymlos (as well as Forteo, although they do not do the generic Forteo—just the name brand for some reason). Their guidelines for approval are narrower than our previous company, but do mention the continuity of care if have been on it for 90+ days. I will follow suggestions and keep in mind your kind offer of specific help, thank you so much! I will get with my physician right away and provide her with the forms the insurance company require from her, supporting the prescription …

REPLY
babbsjoy | @babbsjoy | Dec 8 9:25am
In reply to @sueinmn "@babbsjoy Congratulations on being proactive in managing your care, insurance changes often carry unhappy surprises. First,..." + (show)
@sueinmn

@babbsjoy Congratulations on being proactive in managing your care, insurance changes often carry unhappy surprises.

First, if at all possible, get a refill of your Tymlos prescription to tide you over while negotiating with the new company! We had this issue last year and nearly ran out of one crucial medication.

Second, do not assume that because the new company uses the same pharmacy that they use the same formulary & the same rules.

Your next steps are-
Get a copy of the new insurance plan Drug Formulary (list of covered drugs) and the list of codes that indicate what actions are required before the will fill your prescription - prior approval, what the standards are for approval, etc.
Determine if the specialty pharmacy fills orders for this drug under the new plan (we found out that it is not always the case), otherwise you may need to find a new supplier.
Finally, get a copy of the appeals process for any denials in writing - with the contracted timelines for response.

We have been under a new pharmacy plan this year with my long-time insurer. The new plan not only used the same pharmacies, it had exactly the same Pharmacy Benefit Manager.
Yet they not only required new Prior Approvals for medications we were already using, but also denied those approvals and I had to appeal.
To add insult to injury, they stopped supplying said medications through their Mail Order, but failed to notify us that they did it, filling was delayed by weeks as we had to find a local supplier and pay a higher price.
Just when I thought I had seen everything, the real surprise came yesterday, when they refused a medication I have used for over 10 years, and said I had to go back and repeat the "step therapy" to prove I need it - and it is a generic drug!

I hope you have smoother sailing!

Jump to this post

@sueinmn
Thank you for your detailed response, i have used it to look up the information you suggested and can more clearly see the path I have to take now! It blows my mind all you have gone through with continuity of care, this is all so crazy and I never would have imagined it could be going on in our country! I hope your situation is getting taken care of with relative ease! I am not looking forward to the process, and am concerned about the time it will take. I just received my December pen of Tymlos and will start it on the 11th, so if I’m not to miss doses in January the race is on (during the holidays ) to get some of this squared away! It would be really helpful if we had our new insurance cards with member numbers, but won’t have those until January 1…..but I’ll do what I can until then!

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