1. < Osteoporosis & Bone Health

Insurance is rejecting Tymlos after 90 days

Posted by mary1951 @mary1951, Feb 6 8:21pm

So I was sent my first month of Tymlos last week. A few days later I get a letter stating that they are limiting the drug to 90 days , and that in order to continue to receive it (I paid $66) I will need my prescriber to show that I meet certain requirements, or request an exception.

Has anyone else been through this? I don't want to start the drug if I have to stop it in 3 months! And I certainly can't afford $3100 a month.

Is Tymlos covered under Medicare plan D? I have Aetna Medicare Advantage plan and Silverscript for Part D which I am realizing is not adequate when you start to have serious health issues!

I may be wrong, but I think I can still switch to Medicare for 2025, if I act quickly. Anyone know? All of this has been so complicated, and I have been given so much incorrect info by everyone I have talked to at SilverScript!

It's bad enough to have this diagnosis, but it shouldn't be this hard to treat it!

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njx58 | @njx58 | Feb 7 4:43am

Tymlos can be covered under Part D, but that doesn't mean a given insurer will cover it. Even if they do, they may have conditions like "must have tried X drug first." I had to get my doctor to send a "letter of necessity" to the insurer.

Wellcare dropped coverage for it this year. I have Blue Cross, and they only covered it because I had already been taking it for a year; otherwise, if I were new to it, they would have required Prolia or some such as a first treatment.

I don't think switching to Medicare will help you because you will still need to get a Part D plan from an insurer, and as I described, there are no guarantees. Even if you find that Tymlos is covered, it might not be approved for you personally.

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gently | @gently | Feb 7 6:28am

Switching can be tricky there is a January-March option, but it requires certain conditions. https://medicareguide.com/medicare-advantage-to-original-medicare-165588#:~:text=Medicare%20Annual%20Election%20(%E2%80%9CMedicare%20Open,in%20favor%20of%20Original%20Medicare. You might call Medicare.
You could qualify for Tymos assistance https://radiuspharm.com/radius-assist/ But your income has to be pretty low.
Does your Advantage Plan have an out of pocket maximum option?
Mary, I'd switch anyway, even if it isn't until next year.
In your situation, I'd take the three pens and have the medical office press for the approval.
There is the off chance that you wouldn't tolerate the medications. The first pen will tell you.
Taking the medication for three months will leave you a little safer meanwhile.
Lots of people are having to wait for approval for these medications. At least you plan is sending you a little protection, some don't. Because they are sending the first three, I think they will approve the year.

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1 reply
oopsiedaisy | @oopsiedaisy | Feb 7 7:14am

This happened to me but I was on private insurance (Cigna) through my employer. It was very annoying because I had a prior authorization for the full two years. Why approve and have someone start on a medication if you plan to pull it after 3 months.

I was told by Cigna that I hadn’t used generic Forteo first to see if it worked for me. Not sure why that wasn’t communicated to start. It then took nearly three months to get my prescription filled due to communication issues between the specialty pharmacy, Cigna, and my doctor.

I’ve been on teriparatide for two months now so we’ll see what happens at the end of three months.

I’m sorry to hear you are going through this and hope you can get it straightened out.

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1 reply
mary1951 | @mary1951 | Feb 7 8:13am
In reply to @gently "Switching can be tricky there is a January-March option, but it requires certain conditions. https://medicareguide.com/medicare-advantage-to-original-medicare-165588#:~:text=Medicare%20Annual%20Election%20(%E2%80%9CMedicare%20Open,in%20favor%20of%20Original%20Medicare. You..." + (show)
@gently

Switching can be tricky there is a January-March option, but it requires certain conditions. https://medicareguide.com/medicare-advantage-to-original-medicare-165588#:~:text=Medicare%20Annual%20Election%20(%E2%80%9CMedicare%20Open,in%20favor%20of%20Original%20Medicare. You might call Medicare.
You could qualify for Tymos assistance https://radiuspharm.com/radius-assist/ But your income has to be pretty low.
Does your Advantage Plan have an out of pocket maximum option?
Mary, I'd switch anyway, even if it isn't until next year.
In your situation, I'd take the three pens and have the medical office press for the approval.
There is the off chance that you wouldn't tolerate the medications. The first pen will tell you.
Taking the medication for three months will leave you a little safer meanwhile.
Lots of people are having to wait for approval for these medications. At least you plan is sending you a little protection, some don't. Because they are sending the first three, I think they will approve the year.

Jump to this post

Thanks for your thoughtful reply, Gently. You make a lot of sense.

REPLY
mary1951 | @mary1951 | Feb 7 8:17am
In reply to @oopsiedaisy "This happened to me but I was on private insurance (Cigna) through my employer. It was..." + (show)
@oopsiedaisy

This happened to me but I was on private insurance (Cigna) through my employer. It was very annoying because I had a prior authorization for the full two years. Why approve and have someone start on a medication if you plan to pull it after 3 months.

I was told by Cigna that I hadn’t used generic Forteo first to see if it worked for me. Not sure why that wasn’t communicated to start. It then took nearly three months to get my prescription filled due to communication issues between the specialty pharmacy, Cigna, and my doctor.

I’ve been on teriparatide for two months now so we’ll see what happens at the end of three months.

I’m sorry to hear you are going through this and hope you can get it straightened out.

Jump to this post

@oopsiedaisy. you said, " Why approve and have someone start on a medication if you plan to pull it after 3 months."

My thoughts exactly! I particularly wanted to use Tymlos, so I could titrate. Maybe after 3 months my body will be used to the extra PTH boost, and I'll be able to tolerate Forteo, though the bone pain I'm hearing about sounds really awful.

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