Hi babs10. Sorry it's taken me so long to get back to you.
The way my Medicare AARP UHC Plan D works for Forteo is:
Deductible phase: I pay the full cost of Forteo up to the deductible (which is $545), then I'm kicked into the Initial phase.
Initial phase: I pay a copay (or coinsurance) and the plan pays the rest. Net, my copay and what the plan pays together go towards the $5030 donut hole. Then I'm kicked into the Coverage Gap phase (or Donut Hole).
Coverage Gap Phase (Donut Hole): I pay 25% of the total cost until I reach $8000 (or Catastrophic Phase). Then I'm kicked into Catastrophic Phase.
Catastrophic Phase: I pay $0 cost.
For me I'm paying roughly $3327 full year for the cost . My plan payment by month will be April ($1550), May ($1166), June ($610), July-Dec ($0). Forteo is so expensive (retail $4633/mo) that I only pay out of pocket for the first three months.
I should note that my $3327 full year cost does not include pharmacy administrative fees or needles. I don't know what that cost is yet.
Yes, this is still expensive, however, I don't qualify for the various discounts through the manufacturer or other. After reading this string of comments from others, I will see if my doctor's office can provide any assistance with a better plan/cost. Thank you to everyone else for that insight!
If you haven't already done this, you should go to either Medicare.gov or your Plan D Anthem BC/BS and they should have an tool that will break this out based on your plan.
Just fyi, if I remember correctly, under the Inflammation Act signed by Biden, the Catastrophic Phase will be $2000 in 2025. Again, if I understand this correctly, all our out-of-pocket drug costs will be capped at $2000, then we pay $0. I may be wrong. I hope not (:->). But who knows what will happen in an election year.
Hi babs10. Sorry it's taken me so long to get back to you.
The way my Medicare AARP UHC Plan D works for Forteo is:
Deductible phase: I pay the full cost of Forteo up to the deductible (which is $545), then I'm kicked into the Initial phase.
Initial phase: I pay a copay (or coinsurance) and the plan pays the rest. Net, my copay and what the plan pays together go towards the $5030 donut hole. Then I'm kicked into the Coverage Gap phase (or Donut Hole).
Coverage Gap Phase (Donut Hole): I pay 25% of the total cost until I reach $8000 (or Catastrophic Phase). Then I'm kicked into Catastrophic Phase.
Catastrophic Phase: I pay $0 cost.
For me I'm paying roughly $3327 full year for the cost . My plan payment by month will be April ($1550), May ($1166), June ($610), July-Dec ($0). Forteo is so expensive (retail $4633/mo) that I only pay out of pocket for the first three months.
I should note that my $3327 full year cost does not include pharmacy administrative fees or needles. I don't know what that cost is yet.
Yes, this is still expensive, however, I don't qualify for the various discounts through the manufacturer or other. After reading this string of comments from others, I will see if my doctor's office can provide any assistance with a better plan/cost. Thank you to everyone else for that insight!
If you haven't already done this, you should go to either Medicare.gov or your Plan D Anthem BC/BS and they should have an tool that will break this out based on your plan.
Just fyi, if I remember correctly, under the Inflammation Act signed by Biden, the Catastrophic Phase will be $2000 in 2025. Again, if I understand this correctly, all our out-of-pocket drug costs will be capped at $2000, then we pay $0. I may be wrong. I hope not (:->). But who knows what will happen in an election year.
Hi babs10. Sorry it's taken me so long to get back to you.
The way my Medicare AARP UHC Plan D works for Forteo is:
Deductible phase: I pay the full cost of Forteo up to the deductible (which is $545), then I'm kicked into the Initial phase.
Initial phase: I pay a copay (or coinsurance) and the plan pays the rest. Net, my copay and what the plan pays together go towards the $5030 donut hole. Then I'm kicked into the Coverage Gap phase (or Donut Hole).
Coverage Gap Phase (Donut Hole): I pay 25% of the total cost until I reach $8000 (or Catastrophic Phase). Then I'm kicked into Catastrophic Phase.
Catastrophic Phase: I pay $0 cost.
For me I'm paying roughly $3327 full year for the cost . My plan payment by month will be April ($1550), May ($1166), June ($610), July-Dec ($0). Forteo is so expensive (retail $4633/mo) that I only pay out of pocket for the first three months.
I should note that my $3327 full year cost does not include pharmacy administrative fees or needles. I don't know what that cost is yet.
Yes, this is still expensive, however, I don't qualify for the various discounts through the manufacturer or other. After reading this string of comments from others, I will see if my doctor's office can provide any assistance with a better plan/cost. Thank you to everyone else for that insight!
If you haven't already done this, you should go to either Medicare.gov or your Plan D Anthem BC/BS and they should have an tool that will break this out based on your plan.
Just fyi, if I remember correctly, under the Inflammation Act signed by Biden, the Catastrophic Phase will be $2000 in 2025. Again, if I understand this correctly, all our out-of-pocket drug costs will be capped at $2000, then we pay $0. I may be wrong. I hope not (:->). But who knows what will happen in an election year.
I think my insurance is similar and the $8000 is the catastrophic cap. I am having trouble getting Forteo approved still. I’m waiting for my endocrinologist to apply for an appeal.
I think my insurance is similar and the $8000 is the catastrophic cap. I am having trouble getting Forteo approved still. I’m waiting for my endocrinologist to apply for an appeal.
Hi clairemcl, I'm meeting with my endo next week to review pre-Forteo tests and discuss next steps. I'm assuming this includes her prior approval for the insurance company. May I ask why your insurance is denying approval? In case I'm facing the same.
Hi clairemcl, I'm meeting with my endo next week to review pre-Forteo tests and discuss next steps. I'm assuming this includes her prior approval for the insurance company. May I ask why your insurance is denying approval? In case I'm facing the same.
I have osteoporosis but have had no fractures and I have not tried other less expensive drugs. I have severe scoliosis and spinal stenosis and found out about the osteoporosis when the spine doctor recommended surgery. I can’t have surgery without the bone building, hence Forteo.
I have osteoporosis but have had no fractures and I have not tried other less expensive drugs. I have severe scoliosis and spinal stenosis and found out about the osteoporosis when the spine doctor recommended surgery. I can’t have surgery without the bone building, hence Forteo.
clairemcl, oh my gosh. I see your issue. I would think given your spine issues and the need for surgery would be enough to satisfy insurance. I'll keep my fingers crossed for you.
I have been on alendronate (generic fosamax) with little benefit. My endo is focused on stronger bone building meds (Forteo/Tymlos) since I'm only 66.
clairemcl, oh my gosh. I see your issue. I would think given your spine issues and the need for surgery would be enough to satisfy insurance. I'll keep my fingers crossed for you.
I have been on alendronate (generic fosamax) with little benefit. My endo is focused on stronger bone building meds (Forteo/Tymlos) since I'm only 66.
Connect
Connect
Like
Helpful
Hug
Hi babs10. Sorry it's taken me so long to get back to you.
The way my Medicare AARP UHC Plan D works for Forteo is:
Deductible phase: I pay the full cost of Forteo up to the deductible (which is $545), then I'm kicked into the Initial phase.
Initial phase: I pay a copay (or coinsurance) and the plan pays the rest. Net, my copay and what the plan pays together go towards the $5030 donut hole. Then I'm kicked into the Coverage Gap phase (or Donut Hole).
Coverage Gap Phase (Donut Hole): I pay 25% of the total cost until I reach $8000 (or Catastrophic Phase). Then I'm kicked into Catastrophic Phase.
Catastrophic Phase: I pay $0 cost.
For me I'm paying roughly $3327 full year for the cost . My plan payment by month will be April ($1550), May ($1166), June ($610), July-Dec ($0). Forteo is so expensive (retail $4633/mo) that I only pay out of pocket for the first three months.
I should note that my $3327 full year cost does not include pharmacy administrative fees or needles. I don't know what that cost is yet.
Yes, this is still expensive, however, I don't qualify for the various discounts through the manufacturer or other. After reading this string of comments from others, I will see if my doctor's office can provide any assistance with a better plan/cost. Thank you to everyone else for that insight!
If you haven't already done this, you should go to either Medicare.gov or your Plan D Anthem BC/BS and they should have an tool that will break this out based on your plan.
Just fyi, if I remember correctly, under the Inflammation Act signed by Biden, the Catastrophic Phase will be $2000 in 2025. Again, if I understand this correctly, all our out-of-pocket drug costs will be capped at $2000, then we pay $0. I may be wrong. I hope not (:->). But who knows what will happen in an election year.
I hope this helped.
-
Like -
Helpful -
Hug
3 ReactionsThanks so much for this information which prompts me to look further and try harder.
I also understand that Biden's cap would be $2000 which would help so many by so much! As you said, time will tell.
-
Like -
Helpful -
Hug
5 ReactionsI think my insurance is similar and the $8000 is the catastrophic cap. I am having trouble getting Forteo approved still. I’m waiting for my endocrinologist to apply for an appeal.
-
Like -
Helpful -
Hug
1 ReactionHi clairemcl, I'm meeting with my endo next week to review pre-Forteo tests and discuss next steps. I'm assuming this includes her prior approval for the insurance company. May I ask why your insurance is denying approval? In case I'm facing the same.
-
Like -
Helpful -
Hug
1 ReactionI have osteoporosis but have had no fractures and I have not tried other less expensive drugs. I have severe scoliosis and spinal stenosis and found out about the osteoporosis when the spine doctor recommended surgery. I can’t have surgery without the bone building, hence Forteo.
-
Like -
Helpful -
Hug
1 Reactionclairemcl, oh my gosh. I see your issue. I would think given your spine issues and the need for surgery would be enough to satisfy insurance. I'll keep my fingers crossed for you.
I have been on alendronate (generic fosamax) with little benefit. My endo is focused on stronger bone building meds (Forteo/Tymlos) since I'm only 66.
-
Like -
Helpful -
Hug
1 ReactionI’m 67. Often using a walker since my legs aren’t working well.
Well, I will do what I can!