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Financial discussions/tips concerning expensive treatment
The last 2 days have seen some pertinent posts in regard to how and what to do to secure help for the expensive treatments/ the shots Forteo- Tymlos-Evenity. I am nearing a time of actually pulling the trigger on potentially taking Forteo. though I suppose Tymlos could be in the mix as well. This is my situation. I am currently with a commercial insurance company , Highmark, formerly and still connected to Blue Shield of NY. I am 66 and have got Medicare Part A, but not B. My husband is still working and will be for the foreseeable future ,unless something unforeseen occurs. In January of this year I called my commercial insurance company and was told at the time that it would cost me $ 1,989.40 per month under my existing plan- which is a high deductible plan. Then I contacted Forteo.com and went to savings and support and was told that I could pay $4.00 per month with a coupon up to 9,000 annually, which would be about 4 1/2 months ,leaving the remaining 8 months , which would cost me $17,904.00. That could be repeated for the second year using the $4 coupon for that time up to $9,000 ,again. Because the cost is so high I brought that up to my endo as I feel like cost does factor in one's decision. His response was," I don't want
you to be concerned with that as part of your decision making process.." I was perplexed how he could say that, but because I wasn't planning to do anything right then I let it go. Then on a follow up endo appt , with different dr, as my original one was a Fellow and had left the hospital to move on . Again, when I brought up the cost she said , "Don't worry, once you decide you are going to start treatment we have a person here that works with that end of things." As I look to potentially starting treatment after Christmas , and knowing that changes of insurance and all are abound till Dev 7th , wondering if I should possibly be signing up for Part B, or not? We will still be continuing our family plan as our youngest is 22 , and I believe we can carry her till she's 26.Not sure where and how to spend my energies in figuring this out OR to just let it fly with the response from the endo and trust they'll come up with something. And does, in that situation, essentially come down to what your income is ??
Any and all information is wanted!! THANKS SO MUCH for reading this to the end as I think there are lots of people out here that are grappling with the finance dilemma!!! .
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Hey Windy. For you and anyone else on osteoporosis meds covered under Medicare Part D, there have been some changes for 2024 and there will be even more in 2025.
Might want to review what the Medicare Rights Center has recently written. https://www.medicareinteractive.org/pdf/2024-medicare-costs-guide.pdf
The prior auth was submitted this month, I have ACA, and in the insurance 2024 formulary, it says that Evenity is "excluded". As far as coverage for other OP meds, nothing has changed. My out-of-pocket costs per month will be 50%, so I will definitely hit my MOOP for the year. The acromym MOOP makes me laugh everytime.
@ans not sure where you are in the process of getting forteo. In my case, I have private insurance which uses Accredo specialty pharmacy, and they use manufacture Save-on-SP 1-800-683-1074 for copay assistance, which renders me $0 out of pocket. I don't know the intricacy of the process though, since everything was arranged from my doc's office and the specialty pharmacy called me when it's done (Im very grateful!). I only realized later how expensive these pens are!
One thought, if you decide on forteo, could you start in the middle of the year and get your copay assistance $9000 annually for 3 years?
I just found out about another Amgen program thanks to a post by @dianeg77 in the "Evenity Cost" thread. https://connect.mayoclinic.org/comment/999636/
It's the Amgen Support+ Co-pay Program. It's like other co-pay assistance programs where you're given a card with a benefit value that you can use towards your co-pay or co-insurance. With Evenity, the benefit amount is $8000 and you get 3 years to use it.
I enrolled, and got the card details straight away. I've scheduled my first injection after conferring with three specialists who all agree that it's the best treatment for me at this time.
But are those discounts only available to those under 65?
That's a very good question. Here's the full eligibility criteria from the terms and conditions:
I. ELIGIBILITY
*Eligibility Criteria: Subject to program limitations and terms and conditions, the Amgen SupportPlus Co-Pay Card is open to patients who have been prescribed an Amgen SupportPlus product and who have commercial or private insurance that covers an Amgen SupportPlus product, including state and federal plans commonly referred to as "healthcare exchange plans." This program helps eligible patients cover out-of-pocket medication costs related to an Amgen SupportPlus product, up to program limits. The Amgen SupportPlus Co-Pay Card does not cover any other costs related to office visits or administration of an Amgen SupportPlus product. There is no income requirement to participate in this program.
This offer is not valid for patients whose prescription for an Amgen SupportPlus product is paid for in whole or in part by Medicare, Medicaid, or any other federal or state healthcare program. It is not valid for cash-paying patients or where prohibited by law. A patient is considered cash-paying where the patient has no insurance coverage for an Amgen SupportPlus product or where the patient has commercial or private insurance but Amgen in its sole discretion determines the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of an Amgen SupportPlus product prescription. This offer is only valid in the United States, Puerto Rico, and the US territories.
Yes that leaves out folks on Medicare.
I'm also on Medicare, was diagnosed with 5 fractured vertebrae and need to start Tymlos.
I called medicare and they said to ask my doctor to apply for a tier exemption, so they can charge at a lower tier price? I haven't done so yet. In the meantime I received a notice from Accredo, the pharmacy my drugplan is connected with and they said that my first 3 month supply would cost $3,328, and after that I pay 25% but don't know how much that will be.
Does that seem reasonable?
If you meet income requirements, you can get free Tymlos through Radius Assist. In my state there is also assistance for the donut hole, also with income limits.
I agree 100% and further, some insurance companies cover some medications and not others. It makes no sense to me. I, for example, have two choices - Prolia and Forteo and that's it while others have multiple options.