Drug coverage

Depending on her income she might get help from the company but it’s not likely. From what I understand, Medicare is more apt to cover infusions or those injected by healthcare providers and of course Fosamax etc

It’s most likely that a prior authorization will be required for any of the 3 anabolic bone builders (Forteo or its generics, Tymlos, or Evenity), even if the drug is on the formulary.

If you have private insurance, you can often use a manufacturer’s coupon to offset the copay. I did this and paid nothing out of pocket.

If you have Medicare, most manufacturer coupons are not allowed. However, Part D has a yearly out of pocket max of $2,100 for 2026. Evenity is typically billed under Part B because it is administered by a healthcare provider in most cases, so you may still face a copay. I’m less familiar with the details of Part B coverage and hope others can share their experiences.

per another poster, if a Dr prescribes Fosamax and you say it makes you "sick" (google the symptoms) then he can say that you could not tolerate it and try to get approval for a bone builder. Another poster went thru the appeals process with her insurance company and finally got it approved. For what it's worth....
Good luck

I need a medication and it’s not covered. I have the Medicare deductible $2100 and they told me I can break it up monthly. However I did receive in the mail from my insurance Aetna ppo plan that sent me a form to dispute their decision and why it was rejected. Apparently they just needed more information from my doctor as to why this particular drug was needed. I see my doctor in a few days and I’m bringing her the form to fill out and send back in to insurance. The drug is for Actemra (tocilizumab). It sounds like they will allow it with proper medical notes from rheumatologist.

51% of denied pharmaceutical requests were overturned on appeal.

Thank you.

Sent from Yahoo Mail for iPhone

If you enter Tymlos denial and United Healthcare in the search bar, you will find the steps required to overturn insurance denials. Always remember that for profit companies should never have been allowed to enter the healthcare sector for their commitment to their stock holders will always take precedent over the wellbeing of both patients and healthcare workers. As a RN of 54 years, I have witnessed how the amoral insurance decision makers devastate people’s health resulting in morbidity and sometimes death. Healthcare is a human right since you cannot thrive without your health just as you cannot survive without air and water. Be persistent and fight for what you are entitled to as a human being, though animals deserve good health as well. Good luck in your journey. Take care.

@janetlee2026 Yes, sometimes the problem is not enough information from the doctor (or, more likely, the doctor's assistant.)

That’s what I’m talking about

@janetlee2026

Is that original Medicare?