Does Medicare Cover Forteo?

Forteo is a medication that is used to treat osteoporosis. Its effects include increased bone mass and strength to delay bone loss in patients with osteoporosis.

If you or a loved one suffer from osteoporosis, a common question many people have is, “Does Medicare cover Forteo?” In this article, we answer the question in clear, plain English. You will also find the average costs of Forteo and other helpful info.

The short answer is yes; Medicare will cover the cost of Forteo. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your Forteo. Below we look at what these are so you know what to expect.

Original Medicare

Original Medicare (Medicare Part A and Part B) provides coverage for Forteo. Original Medicare provides coverage for your Forteo if your doctor considers it medically necessary. Your healthcare provider must first order the medication for Original Medicare to provide coverage.

Medicare Part A covers Forteo if your doctor administers it in an inpatient setting.

Coverage for the administration of Forteo is provided by Medicare Part B. Medicare Part B will provide coverage for Forteo if you get it in an outpatient setting. Medicare Part B will provide coverage for Forteo if it is administered as a part of a medical procedure undertaken to stabilize the patient’s health in an emergency situation where treatment is given at the hospital.

Once approved, Medicare Part B covers 80 percent of the costs of Forteo. You will pay for the remaining 20 percent.

Medicare Advantage

Medicare Advantage plans (Medicare Part C) also provide coverage for Forteo. They cover everything Original Medicare covers, as well as some additional benefits.

Precisely what it covers and how much the out-of-pocket costs vary depending on your plan’s specifics. Part C plans that include prescription drug plans will also provide coverage for medications your healthcare provider will prescribe to you.

Medicare Part D plans also provide coverage for Forteo. Medicare Part D is a prescription drug plan. Like Medicare Part C, Medicare Part D plans are provided by private insurance companies. Ninety-three percent of both Medicare Part C and Part D plans provide coverage for the medication Forteo.

Most Medicare plans restrict the amount of purchase for Forteo you can get at a time. If you need to purchase more than the allowed amount of Forteo at one time, Medicare may not cover it.

In this case you can either wait until the period has passed before refilling or if you need to purchase greater amounts of Forteo in just one purchase, you can contact your plan provider and ask for an exception.

The Medicare drug formulary lists Forteo as a tier 5 drug. Most of the time, the Medicare drug formulary only has five tiers. Tier 5 medications are more expensive than Tier 1, 2, 3, and 4 medications.

Most Medicare plans may also require you to have prior authorization before providing coverage for this medication. The usage of this medication has to be for medically necessary purposes. You must contact your plan provider to get authorization.

How Much Does Forteo Cost

The average cost of a single pen (2.4ml) of 20 mcg/dose of Forteo is around $5,800.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.