What You Need to Know

How much your insurance company pays for your osteoporosis medication depends on the type of insurance plan you have. Osteoporosis medications require a prescription from your healthcare provider. They include oral medications that patients take by mouth, such as tablets and liquids. They also include injections that patients give themselves at home as well as nasal sprays and patches. The different types of osteoporosis medications are listed in the table below.

You may pay a certain amount of money or copay for these medications. Most insurance companies have a formulary that lists the prescription medications that your insurance company has approved to pay either in part or in full. Once you understand how much your insurance will pay, you will then know what you need to pay for the medications you use to prevent or treat osteoporosis.

Below is a list of medications your doctor may prescribe for you to help prevent or treat osteoporosis.

Medications to Prevent and Treat Osteoporosis

Understanding the Medicare Part D Prescription Drug Benefit

Medicare pays for prescription medications through the Medicare Prescription Drug benefit, also called “Part D”. This benefit is available to everyone with Medicare and may help lower the cost of your prescription drugs. If you want to have Part D drug benefits, you must sign up for a Medicare prescription drug plan by choosing the one that works best for you. The information below will help you understand how the program works and where you can go for help.

Enrolling in a Medicare Prescription Drug Plan

You can change your choice of plans if you are already enrolled in a Part D plan between November 15th and December 31st of each year.

You must sign up for Medicare Part D between three months before and three months after your 65th birthday, or between November 15th and December 31st of each year. If you enroll in Medicare Part D outside of this time frame, you may have to pay a higher fee as long as you have Medicare prescription drug coverage.

Some people have prescription drug coverage through a union or former employer. If this pays as well or better than Medicare, it is called “creditable coverage.” If you have this type of coverage, make sure your union or employer sends you information on your prescription benefit. This will help you to determine if it qualifies as “creditable coverage.” If you have “creditable coverage,” you can decline Medicare’s prescription drug coverage and not have to pay an extra fee if you enroll later.

How to Choose a Medicare Prescription Drug Plan

There are different Medicare Part D plans available to you, and each plan is different. How much you will have to pay for your medications will vary depending on which Part D plan you choose. Therefore, before you enroll in a plan, you should make a list of all the prescription drugs you take and how much they cost. You can then compare the plans to decide which one is best for you. Be sure you keep your osteoporosis medications in mind as you review Part D plans. To compare plans, you may:

• Call 1-800-MEDICARE (1-800-633-4227) (correct). TTY users should call 1-877-486-2048 (correct).
• Call your State Health Insurance Program (telephone numbers are listed in the Medicare & You Handbook available at www.medicare.gov).
• Visit www.medicare.gov on the internet and select “Compare Medicare Prescription Drugs Plans”.

If you enroll in a Medicare Part D plan, you will probably pay a monthly fee or “premium” for your prescription drug coverage. This fee is different for each plan. The fee you pay for Medicare Part D is an additional fee. In other words, you must pay this fee in addition to the monthly fee you already pay for your Medicare Part B benefits.

You may also have an annual deductible. This is the amount you must pay for your medications before Medicare begins to pay for them. You also will have to pay a portion of the cost of your medications. This is called a copayment or coinsurance. Your costs will depend on three things: 1) which plan you choose; 2) the medications you take; and 3) whether you are eligible to receive extra help paying for your costs through a low-income subsidy.

For further information on the Medicare Prescription Drug Benefit you may call the Centers for Medicare & Medicaid Services at 1-800-MEDICARE (1-800-633-4227) (correct) or visit www.medicare.gov on the web.

Part D Low-Income Subsidy (LIS)

If you have Medicare and limited income and resources, the Social Security Administration (SSA) may help you pay the costs of your Medicare prescription drug plan. The SSA can also help you find organizations in your community that may help you to enroll in a Medicare prescription drug plan.

Medications Given by a Healthcare Professional

Most insurance companies cover medications given by a healthcare professional in a medical office or hospital. The amount you pay for these types of medications is different from what you might pay for a medication you pick up at the pharmacy. If your doctor prescribes an osteoporosis medication that must be given in a healthcare provider’s office through an intravenous infusion or injection, you should find out how much your health plan pays for this type of medication, as well as how much it will cost you. These medications may include ibandronate (Boniva®) and zoledronic acid (Reclast®) and sometimes Calcitonin (Miacalcin®).

What is Prior Authorization?

Your health insurance company may ask that you or your doctor get “prior authorization” before the insurance company will agree to pay for certain treatments or services. By reviewing your condition and the prescribed treatment with you or your doctor, your insurance company can decide if it will pay for the medication. Sometimes, your doctor will call before you receive these treatments to find out if your insurance company needs prior authorization. If you do not know if your insurance plan needs prior authorization, you may call and ask.

Each insurance company has its own prior authorization process. Some may ask your doctor to send a letter that explains why the treatment is necessary. Other insurance companies may take the information over the phone or by fax. If you are asking for prior authorization yourself, it is often helpful to have a letter from your doctor telling why they have prescribed the treatment for you. When you call your insurance company to inquire about prior authorization, you will want to ask these questions:

Appealing Insurance Denials

When you receive treatment in your doctor’s office or pick up a prescription at the pharmacy, your doctor or pharmacist will submit a claim to your insurance company. If it is denied, you or your doctor may need to call the insurance company. Sometimes your insurance company will not pay for a treatment even if you or your doctor follow the prior authorization or claims submission steps as you were told to do. Often a denial is simply the result of errors or incomplete information being given to the insurance company. In most cases you can simply make the necessary changes and resubmit the claim or prior authorization request to the insurance company.

Though coverage denials can be frustrating, it is important for you to remember that an initial denial is not final and may be changed if you file an appeal. When you file an appeal, you are asking your insurance company to review the denied request. The appeals process varies among health insurance plans, so you will need to call your insurance company to learn the steps you need to take. We have listed some questions below that you will want to ask your insurance company when you call to ask about filing an appeal:

Most insurance plans require that you or your doctor write an appeal letter with information about your medical history, condition, previous therapies and why a certain medication is being prescribed for you. No matter what type of insurance you have, you have the right to file an appeal.

Prescription Assistance

The Partnership for Prescription Assistance (PPA) brings together drug companies, doctors, other healthcare providers, patient advocacy organizations and community groups to help you get access to the medications you need if you are uninsured and qualify for help. On the PPA website you can find information on over 475 public and private patient assistance programs. PPA will direct you to public or private programs that can best meet your needs. You can also learn how to contact government programs you may qualify for, such as Medicaid or Medicare.

If you need assistance or would like additional information on the PPA, contact information is provided below.

Manufacturer Sponsored Patient Assistance Programs

Many drug manufacturers offer help to patients who cannot afford to pay for their osteoporosis treatments. The following table provides a list of manufacturer-sponsored drug programs and the phone number for each program. Please call the program directly to find out what support is available and how a you may apply for help.