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Tymlos insurance approval
51 year old male with Complex Regional Pain Syndrome type 2 and a year old Osteoporosis diagnosis. My doctor prescribed Tymlos but for over 8 months now my rx has been denied by my insurance company twice. I hate this stupid health care system where an insurance company has more power that a physician specialist; because of them I have lost several months
of valuable bone building time. Has anyone else had issues getting Tymlos approved by your insurance ? It has almost been a year since this medicine was first prescribed. And my doctor even called me last week to see if I could provide him with a working fax number to send the appeal letter to; he said insurance companies hide these fax numbers as way to delay and defer..it just sucks to pay so much for an insurance plan every month when you don’t even get the meds you need. My second question reg Tymlos is, is it worth the wait if I finally do get it approved? My doc wanted me to be on Tymlos for a year or two to improve my t-score. Hopefully I get this rx
approved soon so can begin to build back bone again..
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@alexandercrps
Welcome to Mayo Connect. I have been in your situation where an insurance company limits my prescription options. But it was not for Thymols. I am glad your provider is working with you to get approved.
Have you checked out the drug company's web page for financial assistance?
https://www.tymlos.com/access-and-savings/ .
Unfortunately, the type of insurance limits their help, and it is available only for prescriptions covered by commercial or private health insurance.
About your other question, is it worth pursuing? There is a new discussion about Tymlos Success you might want to read:
https://connect.mayoclinic.org/discussion/tymlos-success/
I have a Medicare advantage plan. I had to take oral biphosponates for a year before any other meds would be approved. I believe this is fairly common
I ran into similar issues with commercial insurance. When I was first prescribed Tymlos, our then insurance company approved it based on my physician recommendation and my severe t score numbers—despite the fact that I had not fractured. I already have GERD, so bisphosonate meds are not recommended. I was on Tymlos for about five months. BUT then my husbands company changed insurance companies. I was repeatedly denied Tymlos. A rep told me that before appealing, see if my doc would speak to their doc to plead my case, and get it resolved that way. He said that once an appeal was denied with them, that was it and they would not consider any further.
My doc, I guess, didn’t want to get into that. BUT, she submitted approval for Forteo (or its generic equivalent), and it was approved. The Forteo generic is far less expensive than Tymlos. This might be something to talk with your doctor about. Blessings on getting this resolved. I agree that it is ridiculous that insurance companies can influence our healthcare so dramatically (and also short sighted, seems like it will cost them more in the end if you have to file more claims later when not receiving best care….but maybe they figure we won’t be their problem by then….)
I have Medicare & United Healthcare & whether I go thru my Part D drug insurance or part B, it's 2k for the year. Can't do Prolia or Forteo because of autoimmune issues. The purpose of paying for health insurance is to cover you not deny you coverage. But, they do cover Viagra!!!
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1 ReactionYes, Tymlos is definitely worth the fight for insurance approval. My doctor has a full Department that works on appeal letters. Due to failing to previous medications, I was approved on the appeal.
BTW - I also had a severe case of CRPS, following a botched total hip replacement & lumbar block, that transitioned into Central Sensitization Syndrome. I have been very sensitive and prone to side effects with these osteoporosis medications. The flexibility of Tymlos' adjustable dosing (off-label) is worth its weight in gold to mitigate side effects. My doctor, as well as some that are carrying on some research videos, clearly prefer the Tymlos as the drug of choice. Anyways, have your doc fight the fight and hopefully you will win the appeal. Good luck!! And yes, it sucks that you have to go through this and do this.
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2 Reactions@cathyf31 thank you for your reply. I’m happy to announce that I finally got it approved and dispensed..I am on day 12
now. Trying to stay hydrated as I heard this helps side effects. So far so good though, I mostly feel a tad fatigued and dizzy bending. Other than that it seems to be going ok. I assume it takes a while for the medication to settle properly. The pharmacy said peak effects
are reached after ca 12 months of full dose. I feel comfy with the pen and the needle now;
also it is a tiny needle and I barely feel it, so I am ok with the daily stab in my tummy..
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1 Reaction@alexandercrps Fantastic!! Great to hear. Glad to hear you're tolerating the full dose at this point. Other people in this forum have reported incredible games, even with reduced doses. Best wishes as you continue. Hopefully, your doctor will be ordering P1NP and CTX tests throughout the treatment in order to calculate your P1NP:(CTX/1000) ratio, so you can follow your presumed ( > 150) anabolic state!! The actual bone growth is very slow, so they typically like to wait a year to see it appear on the dexobone scan. In the meantime though that ratio will help you see that you were hopefully building bone at a faster rate than your reabsorbing it. Best wishes!!
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