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TYMLOS Prescription Coverage
If you have some form of health insurance, you probably have prescription drug coverage. This means your health insurance plan may cover the cost of some or all of a medication.
The search tool below may help you figure out which insurance plans cover a TYMLOS prescription, and at what tier. To find out if your plan is listed, select your state, region and the name of your plan. Please note that this tool is provided and maintained by Managed Markets Insight & Technology, LLC and is not managed by Radius Health. Please contact your provider directly if you have any questions, or if your plan is not listed. You do not need a TYMLOS prescription to use this tool.
There are many different factors that determine the cost of a drug, how much an insurance company may pay toward the medication and the amount a patient will be required to pay out-of-pocket. For unfamiliar words and abbreviations that may appear within this tool, and common insurance terms, we've put together a helpful healthcare insurance glossary below.
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Please contact your health insurance company directly. Contact information can usually be found on the back of your insurance card.
Use the drop-down buttons (+) to reveal more information on health insurance tiers and prescription co-pay language.
If you're unsure of what tier TYMLOS falls under, contact your insurance provider directly.
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A patient’s share of the cost of a healthcare service; what percentage they are expected to pay in addition to any deductibles owed.
For example, if the co-insurance is 20% and the plan allows $100 toward an office visit (and the yearly deductible has been met), the co-insurance amount would be $20. The insurance plan would cover the remaining $80.
Also referred to as co-payment. The dollar amount a patient is required to pay for a healthcare service or prescription. Usually co-pays are paid at the time of the doctor visit or when filling a prescription. Co-pay charges can vary based on the type of doctor seen, what services were received or the type of medication.
Prescription drugs, procedures and other medical and healthcare services that a patient’s plan includes. It’s important to note that even though a drug may be covered, a pre-authorization may be required before the health insurance provider will pay.
The amount a patient owes toward healthcare services before the health insurance plan begins to pay. Sometimes, certain services — like preventative care — will be covered by a plan before a deductible is met. Some plans may have separate deductibles for prescription drugs. Family plans may have individual deductibles and family deductibles.
The list of prescription medications that a health insurance plan has agreed to cover and pay for. It’s also commonly referred to as a drug list.
Generic drugs use the same active ingredients as brand-name drugs. After a brand name drug loses its patent protection, generic medications that contain the same active ingredient at the same dose of the brand name drug may become available. Most generic drugs are classified as "Tier 1" under an insurance plan. Tier 1 is sometimes referred to as the "generic tier."
A federal government insurance plan that provides healthcare coverage options and drug benefits for people over 65 years old, or disabled people under the age of 65. There are different parts of Medicare, commonly referred to as Parts A, B, C and D. Part D helps to cover costs of prescription drugs.
If a patient's healthcare provider decides a certain medication is necessary for their treatment but it is not covered by their plan, their healthcare provider can request that it be covered under an exception. The doctor may be asked to provide certain details as to why this particular medication is essential to their care.
This describes a medication that is not on the patient's insurance plan’s pre-approved, preferred drug list, known as a formulary. Non-formulary drugs may cost more, as another option that is on formulary may be available.
A medication is considered “non-preferred” if there is an equivalent drug available that is preferred by a patient's insurance plan. If a drug is considered non-preferred within the plan, the patient can still fill the prescription. A higher co-pay may be required.
This lets a patient know that a medication may be covered but information is currently unavailable. Their insurance provider will be able to provide more details.
Any medication costs that are not covered by a patient's insurance plan. These include co-pays, co-insurance and deductibles. Many insurance plans have yearly out-of-pocket maximums in order to help keep costs down for patients. This means that there is a finite amount they will have to pay for medication or a healthcare service. If the patient reaches the out-of-pocket maximum, their health insurance will then cover 100% of certain services and medications.
An insurance company may elect to put a drug on a preferred tier compared to other similar options. Preferred drugs typically have lower out-of-pocket costs to the patient compared to non-preferred drugs.
Prior authorization (sometimes abbreviated as PA) is when a health plan must pre-approve a healthcare service or a prescription (before it’s filled by the pharmacy) in order for the costs to be covered. There are many reasons a health plan may require prior authorization for a medication.
The term “specialty drug” is an umbrella phrase that may be used to describe a wide range of medications. Specialty drugs may have any of the following characteristics:
- Treats rare diseases, fatal diseases, chronic or complex diseases or progressive illnesses
- has a high monthly cost
- may require special handling, shipping or storage
- can come in the form of an oral, injectable, inhalable or infusible drug product
- may require additional patient education, adherence, support, etc.
Specialty pharmacies process, fulfill and ship specialty drugs not usually available at traditional “brick-and-mortar” pharmacies. Injectables, such as TYMLOS, are traditionally filled through specialty pharmacies.
In certain situations, a patient may be required to try a certain drug before the costs of others will be covered by their plan.
Insurance providers often offer several different levels of healthcare coverage, known as tiers. Tiers play a large role in determining the cost to a patient of a prescription medication. Usually a drug in a lower tier will be less expensive than those in a higher tier. Tiers 1 through 3 are fairly common for generic, preferred and/or brand-name drugs. The higher tiers are often used for specialty drugs.
Below is an example of a tier structure that a plan might use. Note that tier structures can vary greatly among plans. Some plans may only have 2 tiers while others may extend beyond 4 tiers.
- Tier 1: lowest co-pay amount; most generic drugs fall under this tier
- Tier 2: moderate co-pay amount; many preferred and brand-name drugs are in this tier
- Tier 3: usually has a higher co-pay amount and includes non-preferred and brand-name drugs
- Tier 4: generally reserved for specialty drugs, like injectables
It is not known if the drug is covered because it is not listed on the insurance plan’s formulary, or drug list. At this time, coverage cannot be determined, though the drug may or may not be covered.
Things to keep in mind
- Co-pays may vary from plan to plan. If you have any questions, please contact your insurance company directly
- Deductibles can also be a factor for out-of-pocket costs
- Prior authorization (PA), or approval from a health plan before the prescription is filled, may be required in order to receive your TYMLOS prescription.
- For Medicare patients, the out-of-pocket costs for a prescription medication can vary due to income, premiums, co-insurance and supplemental insurance plans. Unfortunately, our Savings Card cannot be used with Medicare coverage due to government regulations. For more information, it's best to consult your specific provider. A contact number can usually be found on the back of your insurance card
If TYMLOS is not covered under your insurance plan, here's what you can do:
- Call your insurance company to let them know you are interested in TYMLOS
- Call Together with Tymlos at
1-866-896-56741-866-896-5674to see if there are other ways to save on your medication