Tymlos and Medicare Part D drug coverage

I don’t have information about Medicare Part D. However, I thought I’d just mention that I’m on a Facebook Tymlos group where I’ve learned that Tymlos has helped subsidized the cost for some who can’t otherwise afford it.

Wellcare dropped Tymlos last year, so no, it's not covered. I had to switch from Wellcare to someone else. Blue Cross is a possibility. Open Enrollment begins in October, so you can shop for a new Part D plan for 2027.

There is a copay benefit card available from the manufacturer, but if you're on Medicare, you're not eligible to use it.

Please do not accept the Tymlos denial from WellCare. A Medicare patient can appeal a denial all the way to the
Office Of Medicare Claims and Appeals that I did and won. The process is arduous but worth it. It took me 9 months to win my Appeal and I started Tymlos in July of this year. I have detailed the entire appeal process in a previous post so you can search this forum’s past posts and find my post by entering Tymlos and United Health CareDenial. It is correct that Medicare recipients are not eligible to receive and use the discount coupon for Tymlos but all Medicare recipients with Part D coverage are protected by law to a limited annual dollar copay of $2100/ for all Category 5 Catastrophic Drugs. This is financially life saving since Tymlos costs over $7000/ month! Persistence in appealing an insurance denial not only can benefit you but others by building a database within Medicare demonstrating the statistical denial incidence rate for each of the Medicare Advantage Insurance programs. Fight for what you need to stay healthy. Take care.

If your health plan is through work, ask if they participate with Prudent Rx. 1-800-578-4403. Call anyway. I am on Medicare, but my supplemental plan is through my work's retirement plan. They partner with Prudent Rx, so my Tymlos is free, no copay and delivered by CVS.

I also have WellCare Part D. I was denied Tymlos and yes it is non-formulary. My doctor's office insurance department appealed the denial and we won. So I started the injections immediately. What did help my case was the fact that I had failed two previous treatments, Boniva and Evenity.

@cathyf31 That is great! Sometimes you can fight the system.

@njx58 Sadly, we shouldn't have to fight the system in order to get the medications that our doctors have deemed necessary. 😞

I had Horizon Part D which covered Tymlos but only after I had paid the large deductible

@2024tymloshelp Well, that's going to be the case for most Part D plans. The max allowed deductible for 2027 will be $700, and the max OOP will rise to $2400. Even a plan that covers Tymlos will cost someone $2400 next year.

@cathyf31 that is helpful. My current part D plan is also Wellcare and generic Forteo is on their formulary and was approved (so there goes 2400 and hoping they don't increase the cap again as they did from last year to next year)---I am starting in January because I am damned if I am going to give the drug companies an extra 2400 by starting it now. They already get wealthy off the backs of most of us, however I have never done well with any daily medicine and I also have Long Covid for 5.5 years which has affected reactions for me, so if I don't tolerate it well or we end up with so many power outages as we have where I live, I don't want to wait another year to try something like Tymlos that is non formulary. My only two options right now (for medical reasons) and the first drugs for me for osteoporosis I have been on so if these fail there is nothing. Not looking forward to any of it. Feel like I am between a rock and a hard place.