Hello! I just was recommended Tymlos from my Endo. Can anyone tell me how much or if it is covered by insurance? I have Blue Cross Blue Shield Federal. TIA.
You will probably need prior authorization from the plan. I would call them to see if Tymlos is covered.
Also, did your doctor explain how to get Tymlos? You can't just bring your script to CVS or Costco or wherever. You have to use a specialty pharmacy (like CVS Specialty.) It took me a while to get everything in order, and my doctor had to send a special prescription form to my plan (available on Tymlos Web site.)
No. She didn't explain any of that. She's pretty abrupt in general. That's another whole subject! I'm going to start by calling my insurance company. I was just curious before doing that.
@yogagirl57
I am about three months into Tymlos. My doctor sent for approval to my commercial insurance, paving the way. I don’t know what all she sent to support her recommendation for this medicine, but after some time, it was approved and I received a letter from my insurance company stating such. My doctor did a lot of prior testing and had a lot to support the need for the med. Another doc, prior to this, just shut it down saying I would never get initial approval for Tymlos (although he agreed it would be best for my case)—that I would almost certainly have to try fosomax or something first…..so the doctor can make the difference. I have heard that if it is not first approved, the doc can go back on appeal and provide more info….so if that happens do advocate for yourself!
That being said, my out of pocket was going to be just over $500 a month. But if you go on the Tymlos website (Radius manufacturer), you can apply for their savings card, since you have commercial insurance and not Medicare. You don’t have to do much to apply, and you receive an approval number immediately . I provided that number to my doctor as well. I called my insurance company, and found out which specialty pharmacies are on their approved list—in that way making sure my copay would be the least possible. I provided those contact numbers to my doc as well.
When all was done and I knew which pharmacy my doc sent the prescription to, I called them to make sure they also had my Radius savings card number. So far, I pay nothing for my Tymlos and the needles and alcohol wipes.
I was thrilled to have access to this med, and hope all works out well for you too!
I just completed 4 months of Tymlos through Cigna and Accredo Specialty Pharmacy. I had a 2-year preauthorization but unfortunately Accredo submitted another request for authorization even though they already had approval for two years. It was rejected because my Cigna plan is not covering Tymlos any more. They want me to switch to the generic version of Forteo (Forteo went off patent recently).
The cost to me during the four months was zero as the manufacturer paid the $800 co-pay.
I think you need to figure out which of these 3 FEP blue drug formularies goes with your exact plan and then use the price-checker tool. They all seem to require a PA, but I believe 99% of plans require PAs for drugs with sticker prices of $2k+ a month. https://www.fepblue.org/pharmacy/prescriptions
If you can afford to pay for your medicine up front and THEN get reimbursed by the manufacturer, you can avoid having to join PRUDENT RX which is (what is called) the co-pay maximizer program that goes with your insurance's pharmacy benefit manager, CVS Caremark. At least give yourself time to learn about what PrudentRX really does before you sign on the dotted line (I hate co-pay maximizers in case you hadn't guessed).
These are all fragments of information that probably sound like Greek and don't make much sense at this point in your journey. I'm happy to share what I know when you get to the phase of paying for the medicine. I believe you'll come out better (by getting reimbursed nearly 100% by the manufacturer after paying direct) for your first several fills at which time you will have met your out of pocket max (mid year? middle of 2nd quarter?) and then the med will be $0 per month paid by your insurance after that.
I experienced sharp intermittent twinges of pain in my extremities and joints (fingers, toes, calves, knees, and forearms). It was unpleasant but not constant. It happened mostly in bed at night or in the morning and not every day. I took my Tymlos dose at bed time.
I’ve been off Tymlos for a week now and they have completely disappeared. I am waiting for approval for my teriparatide prescription to be filled so I am off everything right now.
I experienced sharp intermittent twinges of pain in my extremities and joints (fingers, toes, calves, knees, and forearms). It was unpleasant but not constant. It happened mostly in bed at night or in the morning and not every day. I took my Tymlos dose at bed time.
I’ve been off Tymlos for a week now and they have completely disappeared. I am waiting for approval for my teriparatide prescription to be filled so I am off everything right now.
COST: It will make a difference if you are on Medicare Part D. If so, in 2025 your maximum out of pocket will be $2000, assuming that your plan covers the drug. This is due to the new law put signed by our current President. See photo, from Medicare.gov. Please note the first sentence "PRESCRIPTION DRUGS COVERED BY YOUR PLAN"! If you are on Medicare Part D and your plan does not cover the drug, you need to switch plans NOW!
COST: It will make a difference if you are on Medicare Part D. If so, in 2025 your maximum out of pocket will be $2000, assuming that your plan covers the drug. This is due to the new law put signed by our current President. See photo, from Medicare.gov. Please note the first sentence "PRESCRIPTION DRUGS COVERED BY YOUR PLAN"! If you are on Medicare Part D and your plan does not cover the drug, you need to switch plans NOW!
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You will probably need prior authorization from the plan. I would call them to see if Tymlos is covered.
Also, did your doctor explain how to get Tymlos? You can't just bring your script to CVS or Costco or wherever. You have to use a specialty pharmacy (like CVS Specialty.) It took me a while to get everything in order, and my doctor had to send a special prescription form to my plan (available on Tymlos Web site.)
-
Like -
Helpful -
Hug
2 ReactionsNo. She didn't explain any of that. She's pretty abrupt in general. That's another whole subject! I'm going to start by calling my insurance company. I was just curious before doing that.
@yogagirl57
I am about three months into Tymlos. My doctor sent for approval to my commercial insurance, paving the way. I don’t know what all she sent to support her recommendation for this medicine, but after some time, it was approved and I received a letter from my insurance company stating such. My doctor did a lot of prior testing and had a lot to support the need for the med. Another doc, prior to this, just shut it down saying I would never get initial approval for Tymlos (although he agreed it would be best for my case)—that I would almost certainly have to try fosomax or something first…..so the doctor can make the difference. I have heard that if it is not first approved, the doc can go back on appeal and provide more info….so if that happens do advocate for yourself!
That being said, my out of pocket was going to be just over $500 a month. But if you go on the Tymlos website (Radius manufacturer), you can apply for their savings card, since you have commercial insurance and not Medicare. You don’t have to do much to apply, and you receive an approval number immediately . I provided that number to my doctor as well. I called my insurance company, and found out which specialty pharmacies are on their approved list—in that way making sure my copay would be the least possible. I provided those contact numbers to my doc as well.
When all was done and I knew which pharmacy my doc sent the prescription to, I called them to make sure they also had my Radius savings card number. So far, I pay nothing for my Tymlos and the needles and alcohol wipes.
I was thrilled to have access to this med, and hope all works out well for you too!
-
Like -
Helpful -
Hug
1 ReactionI just completed 4 months of Tymlos through Cigna and Accredo Specialty Pharmacy. I had a 2-year preauthorization but unfortunately Accredo submitted another request for authorization even though they already had approval for two years. It was rejected because my Cigna plan is not covering Tymlos any more. They want me to switch to the generic version of Forteo (Forteo went off patent recently).
The cost to me during the four months was zero as the manufacturer paid the $800 co-pay.
@oopsiedaisy Good to know! How was your 4 months on Tymlos? Did you suffer any side effects?
I think you need to figure out which of these 3 FEP blue drug formularies goes with your exact plan and then use the price-checker tool. They all seem to require a PA, but I believe 99% of plans require PAs for drugs with sticker prices of $2k+ a month. https://www.fepblue.org/pharmacy/prescriptions
If you can afford to pay for your medicine up front and THEN get reimbursed by the manufacturer, you can avoid having to join PRUDENT RX which is (what is called) the co-pay maximizer program that goes with your insurance's pharmacy benefit manager, CVS Caremark. At least give yourself time to learn about what PrudentRX really does before you sign on the dotted line (I hate co-pay maximizers in case you hadn't guessed).
These are all fragments of information that probably sound like Greek and don't make much sense at this point in your journey. I'm happy to share what I know when you get to the phase of paying for the medicine. I believe you'll come out better (by getting reimbursed nearly 100% by the manufacturer after paying direct) for your first several fills at which time you will have met your out of pocket max (mid year? middle of 2nd quarter?) and then the med will be $0 per month paid by your insurance after that.
I experienced sharp intermittent twinges of pain in my extremities and joints (fingers, toes, calves, knees, and forearms). It was unpleasant but not constant. It happened mostly in bed at night or in the morning and not every day. I took my Tymlos dose at bed time.
I’ve been off Tymlos for a week now and they have completely disappeared. I am waiting for approval for my teriparatide prescription to be filled so I am off everything right now.
@oopsiedaisy Thank you for your reply. Happy the symptoms disappeared once you ended the treatment. That's great! Is teriparatide the same at Forteo?
COST: It will make a difference if you are on Medicare Part D. If so, in 2025 your maximum out of pocket will be $2000, assuming that your plan covers the drug. This is due to the new law put signed by our current President. See photo, from Medicare.gov. Please note the first sentence "PRESCRIPTION DRUGS COVERED BY YOUR PLAN"! If you are on Medicare Part D and your plan does not cover the drug, you need to switch plans NOW!
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Helpful -
Hug
3 ReactionsYes. I used Wellcare Value Script this year, but they've dropped Tymlos for 2025, so I am switching to another plan.