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Saturday, November 14, 2009 DN, Community Member, asks

Q: Can someone tell me if medicare pays for Forteo?

I've read some on line answers to this question and I've become even more confused.


Can you tell me which Medicare Part D plan is the best one to sign up with while I'm using this drug?


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Answers (2)
Pam Flores, Health Guide
11/15/09 10:45am

Hi DN, welcome and thanks for your question.  If you are currently trying to decide which Part D plan to choose, you can access most of them online and see if they cover Forteo.  Another option would be to make a list of all the plans you are considering and call each one and ask if Forteo is covered and what the copay price is.  I know some of them cover it, but it has a relatively high copay price.  You might be able to find one that has a lower copay, but the only way to do that is to call each one or look at each companies formulary (covered drugs) online.  Most of the insurances that cover it have it listed as a tier 4 or "specialty med" which "usually" means it cost 20% of the retail price.  I'm not sure what retail is right now but it's around 1,000.00 a month.  So 20% of that isn't cheap.  See if you can't find a plan that has it listed at a lower copay price.


Good luck trying to find one.Smile

Pam Flores, Health Guide
11/15/09 11:12am

Hi DN, I forgot to mention another important question.  You need to ask each insurance that covers Forteo, how soon you'd be in the coverage gap (donut hole) when filling the prescription.  Once you are in the donut hole, you have to pay full retail price, unless you can find a plan that gives you brand name drug coverage during the donut hole.


There's also a possibility that if our Presidents new health plan goes through, the price of brand name drugs, during the donut hole, will be reduced by 50%, but I don't know for sure if this will happen or when.  Some are saying it would be implemented by July 09, but I'm not sure.


I know this is very confusing, but it's best to be armed with as much knowledge as possible.

DN, Community Member
11/15/09 1:33pm


You've summarized exactly what I've been hearing.  What is that "donut hole?" 

Does it mean that my prescription drug plan pays for a drug less the co pay, up to a designated dolllar amount and when that amount has been paid out by the insurer I'm responsible for the entire cost of the prescription? 

It sounds like I have a lot of homework to do.  Thanks for being kind enough to respond. 

DN  Smile

Pam Flores, Health Guide
11/15/09 2:25pm

Hi DN, yes that's correct.  If you go to Medicare or any of the Part D plans it will explain the donut hole and how you reach it.  I don't know off hand what the out-of-pocket figure is but you can find out through either of those sources.  One thing to keep in mind; the figure is calculated by how much you spend "plus" what the insurance pays.  If you have your Medicare Handbook, look at pages 62-76 and it will explain when the donut hole starts (what figure) and when it stops (what figure) see page 66 for a detailed explanation on the donut hole/coverage gap.  Some plans will pay for generics, during the donut hole, and some don't.  If you choose one that does, the monthly premium is higher, but at least you have generic coverage during the donut hole.  The only problem with this is Forteo is a Brand name drug, and doesn't have a generic equivalent, so you have to pay for this once you've reached the limit.  Pay close attention to the Catastrophic Coverage figure, that's when the insurance starts to pay again, at a better rate.  Some never reach this figure, but some do if they are taking very expensive meds.


Occasionally there will be a plan available that has Brand name coverage during the dh, but you have to look at all that are available to see if there is one that is doing this. 


I hope this helps to explain it some, I know it's really confusing and even the doctors don't really get it. Smile


If you can't afford this, you may be eligible for Eli Lily's patient assistance program, but you'd have to go to their web site to see how it works.


Here's a link on my Question of the Week on Patient assistance programs, take a look at it and see if any of the info helps you.  We'd love for you to join our discussion there, and anyone else that's dealing with the high cost of prescription meds.  Make sure to read all the comments on this link above, the last one has a listing for many of the assistance programs and one to Medicare.


Good luck and if I can help further just post again...



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By DN, Community Member— Last Modified: 04/16/13, First Published: 11/14/09