Medicare Coverage for Forteo: A Comprehensive Guide

Forteo is a prescription medication primarily used to treat osteoporosis in postmenopausal women and men at high risk of fractures. This medication works by increasing bone mass and strength, reducing the risk of fractures. It is an injectable medication administered daily for up to two years. Forteo is a highly effective treatment option for individuals with severe osteoporosis or those who have experienced fractures despite other treatments.

Medicare Part A and Part B Coverage

Medicare is a federal health insurance program that consists of different parts, each covering specific healthcare services. When it comes to Forteo, coverage falls under Medicare Part D, which provides prescription drug coverage. However, it is essential to understand the potential coverage provided by Medicare Parts A and B.

Medicare Part A, also known as hospital insurance, typically covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Unfortunately, Medicare Part A does not cover prescription medications like Forteo when administered outside a hospital or skilled nursing facility.

Medicare Part B, also known as medical insurance, covers outpatient services, including doctor visits, preventive care, and medically necessary supplies. However, similar to Part A, Part B does not generally cover prescription medications that are self-administered at home, such as Forteo.

Medicare Part D Coverage

Medicare Part D is the part of Medicare that provides prescription drug coverage. It is offered through private insurance companies approved by Medicare. To obtain coverage for Forteo, you will need to enroll in a standalone Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage.

It is important to note that Medicare Part D plans have formularies, which are lists of covered medications. Each plan’s formulary may vary, so it is crucial to review the formularies of different Part D plans available in your area. When comparing plans, ensure that Forteo is included in the formulary, and consider factors such as monthly premiums, deductibles, copayments, and coinsurance.

Cost-sharing and Coverage Gap

Medicare Part D coverage involves cost-sharing, which means you will be responsible for paying certain out-of-pocket costs. These costs may include monthly premiums, annual deductibles, copayments or coinsurance, and costs in the coverage gap, also known as the “donut hole.”

The coverage gap is a temporary limit on what Medicare Part D plans cover for prescription drugs. Once you and your plan have spent a certain amount on medications, you will enter the coverage gap, and your out-of-pocket costs may increase. However, it is important to note that the coverage gap is gradually being reduced until it is completely phased out by 2020.

Medicare Supplement Insurance

In addition to Original Medicare (Part A and Part B), you may have the option to enroll in a Medicare Supplement Insurance plan, also known as Medigap. These plans are offered by private insurance companies and can help cover some of the out-of-pocket costs associated with Medicare, such as deductibles, copayments, and coinsurance.

However, it is crucial to understand that Medigap plans do not include prescription drug coverage. To obtain coverage for medications like Forteo, you will still need to enroll in a standalone Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage.

Additional Resources

Understanding Medicare coverage for Forteo can be complex, but there are resources available to assist you. Here are some additional sources of information that you may find helpful:

1. Medicare.gov – The official U.S. government website for Medicare provides detailed information about Medicare coverage, enrollment, and prescription drug plans. Visit Medicare.gov for more information.
2. National Institute on Aging – The National Institute on Aging offers resources on osteoporosis, including information on treatment options and Medicare coverage. Explore their website at nia.nih.gov for valuable insights.
3. American Association of Retired Persons (AARP) – AARP is a nonprofit organization dedicated to empowering individuals over the age of 50. They provide comprehensive information on Medicare coverage, including prescription drugs. Visit aarp.org to access their resources.
4. Centers for Medicare and Medicaid Services (CMS) – CMS is a federal agency that administers the Medicare program. Their website, cms.gov, offers in-depth information on Medicare coverage, policies, and regulations.

Summary:

• Medicare coverage for Forteo falls under Medicare Part D, which provides prescription drug coverage.
• Medicare Part A and Part B generally do not cover self-administered prescription medications like Forteo.
• To obtain coverage for Forteo, you need to enroll in a standalone Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage.
• Medicare Part D involves cost-sharing, including monthly premiums, deductibles, copayments, and costs in the coverage gap.
• Medicare Supplement Insurance (Medigap) plans do not include prescription drug coverage, so separate enrollment in a Part D plan is necessary.

Helpful Links:

• Medicare.gov
• National Institute on Aging
• AARP
• Centers for Medicare and Medicaid Services (CMS)