Does Medicare Cover Forteo?
- Get the facts about Medicare coverage for Forteo. Learn how the cost of this osteoporosis drug varies during the four coverage stages of Medicare Part D.
If you have osteoporosis, loss of bone density puts you at an increased risk for fractures. The International Osteoporosis Foundation reports that a bone fracture related to osteoporosis occurs once every three seconds and that one out of every three women over the age of 50 worldwide will suffer a broken bone due to the disease. Forteo is a prescription medication that can lower the likelihood of you becoming a statistic, and the drug is often covered by Medicare.
Does Medicare Cover Forteo?
Medicare Part D is the part of Medicare that covers prescription drugs. A survey of plans conducted by GoodRx revealed that 93% of Medicare Part D plans cover the medication as of October 2021. Enrollment in Medicare Part D isn't automatic. You must sign up for a plan through a private insurer to receive coverage.
What Is Forteo?
Forteo is a medication approved by the FDA for postmenopausal women with severe osteoporosis. The drug involves a once-daily injection administered to the thigh or abdomen with a delivery device that is used for 28 days and then replaced. You can inject the medication yourself at home. The medication is a synthetic version of parathyroid hormone and works by promoting the growth of healthy bone and slowing down the process of bone loss.
Is There a Generic Drug for Forteo?
In July 2021, a generic version of Forteo sold under the name teriparatide became available. GoodRx reports that as of October 2021, most Medicare Part D plans didn't cover the generic form.
What Is the Cash Price of Forteo?
Without any type of insurance coverage, the average price for one 28-day Forteo pen is around $5,300. You may pay more or less depending on where you live and choose to fill your prescriptions.
What Does Forteo Cost with Medicare?
Your out-of-pocket cost for Forteo under Medicare varies based on what stage of coverage you are in:
- Deductible stage. Before you have paid your deductible, you will typically pay the full price for Forteo. If the cost of one dose is more than your deductible, Medicare Part D is likely to pay for a portion of the overage.
- Post-deductible stage. Once your deductible is met, Medicare Part D will pay for Forteo, and you will likely have to pay a copay or coinsurance. Average costs range from $354 to $4,344.
- Donut hole. When the total cost of all of the medications you take reaches a threshold called the donut hole, you pay for 25% of the cost of Forteo. For 2021, the donut hole begins once you and your insurance plan have paid a total of $4,130. The price for Forteo during the donut hole stage is $638 to $4,344.
- Post-donut hole (catastrophic coverage). When your total drug spending exceeds the upper limit of the donut hole, your Medicare Part D plan will usually pay for most of the cost of Forteo. You will usually have to pay a copay or coinsurance. In 2021, the catastrophic coverage begins at $6,550. Because Forteo is an expensive drug, you will likely reach the catastrophic coverage stage quickly.
How Do I Know if Forteo Is Covered by My Medicare Drug Plan?
To find out whether your Medicare Part D plan covers Forteo, check the plan's formulary. The formulary tells you what drugs are covered and which tier the drug falls under. Medicare Part D formularies use the following tiers:
- Tier 1: Preferred generic drug, the least expensive generic medication for a disease or condition
- Tier 2: Other generic drugs that treat that condition
- Tier 3: Preferred brand name drug, the least expensive option that does not have a generic equivalent
- Tier 4: Other brand name drugs
- Tier 5: Specialty or experimental drugs that require more observation
Forteo is typically classified as a Tier 3 or Tier 4 drug by Medicare plans. Your plan's formulary can help you determine how much Forteo will cost.
What Other Medication Is Similar to Forteo?
Forteo is not the only type of teriparatide injections available. The drug is also sold under the brand names Alvogen and Bonsity. Depending on your plan, these drugs may be more or less expensive than Forteo. In addition, the Mayo Clinic states that there are other bone-building medications, including:
- Abaloparatide, sold under the brand name Tymlos, which can be taken for a maximum of 2 years
- Romosozumab, sold under the brand name Evenity, which is a monthly injection administered in a doctor's office
These drugs may or may not be more affordable than Forteo, depending on your plan. Your doctor will decide which bone-building medication is right for you based on your medical history.
Are There Patient Assistance Programs for Forteo?
Lilly, the manufacturer of Forteo, offers a copay card that makes the drug more affordable; however, this program is not open to people who are covered by Medicare.