Medicare Part D covers Binosto, but only if your plan includes it on its formulary

Binosto is a brand-name medication for osteoporosis that dissolves on your tongue. Whether Medicare pays for it depends on your specific Part D prescription drug plan, not on Medicare itself. Each Part D plan maintains its own list of covered drugs, called a formulary, and Binosto appears on some formularies but not others.

If your plan does cover Binosto, you will pay your plan's copay or coinsurance after you meet your deductible. If it does not cover Binosto, your plan may cover alendronate (the generic version), which works the same way but costs less. The only way to know what your plan covers is to check your plan documents or call the customer service number on your insurance card.

Key Takeaways

  • Binosto coverage varies by Part D plan — your specific plan either includes it or does not.
  • If your plan does not cover Binosto, the generic alendronate is almost always a covered alternative that works identically.
  • You can check your plan's formulary online, by phone, or by asking your pharmacy before you fill a prescription.
  • If your doctor believes Binosto is medically necessary and your plan denies it, you can request an exception through your plan's appeals process.

How to check if your plan covers Binosto

Start by finding your plan's formulary. If you enrolled in a Medicare Advantage plan with prescription drug coverage (Part C), your plan documents came with a formulary or a link to one. If you have standalone Part D coverage, your plan sent you a formulary when you enrolled. Both are also available on your plan's website — look for "formulary," "drug list," or "covered medications."

Search the formulary for "Binosto" or "alendronate." The formulary will tell you whether the drug is covered, what tier it is on (which determines your copay), and whether your doctor needs to get prior authorization before the pharmacy can fill it. If you cannot find the formulary or do not know which plan you have, call the number on your Medicare card and ask for the formulary or a list of covered osteoporosis medications.

Your pharmacy can also check coverage for you. When you call or visit, give them your insurance information and ask whether Binosto is covered under your plan and what your copay would be. Many pharmacies can answer this question in minutes.

What to do if your plan does not cover Binosto

If your formulary shows that Binosto is not covered, ask your doctor or pharmacist whether alendronate (the generic version) is an option. Alendronate works the same way as Binosto — both are weekly medications for osteoporosis — and almost all Part D plans cover it because it costs less. Your copay for generic alendronate will likely be lower than what you would pay for Binosto even if it were covered.

If your doctor has a specific medical reason why Binosto is necessary instead of alendronate, you can request a formulary exception. Your plan must have a process for this, usually called an appeals or exceptions request. Ask your doctor's office to submit the request on your behalf, explaining why Binosto is medically necessary for you. The plan has a set number of days to respond — usually 72 hours for urgent requests and up to 30 days for standard ones.

You can also switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year) if your current plan does not cover the medication you need. When comparing plans, use the plan finder tool on Medicare.gov and search for Binosto to see which plans include it.

Understanding Binosto's cost under Medicare

If your plan covers Binosto, your out-of-pocket cost depends on which tier the plan places it on. Most plans put brand-name drugs on a higher tier than generics, which means a higher copay. You might pay $15 to $50 per prescription, depending on your plan and which tier Binosto is on.

Your copay counts toward your deductible and your out-of-pocket maximum. Once you reach your plan's out-of-pocket maximum for the year, Medicare and your plan cover all remaining prescription costs. The out-of-pocket maximum for Part D in 2024 is $7,050, though your plan may have a lower limit.

If cost is a concern, talk to your doctor about whether alendronate would work for you. The generic version typically costs $10 to $20 per month with most Part D plans, making it significantly cheaper than Binosto.

When your doctor prescribes Binosto

If your doctor writes a prescription for Binosto, give it to your pharmacy along with your insurance card. The pharmacy will check your coverage and tell you whether the prescription can be filled and what you will owe. If your plan requires prior authorization, the pharmacy will usually contact your doctor's office to get it — you do not have to do this yourself.

If the pharmacy tells you that Binosto is not covered, ask them to check whether alendronate is covered instead. You can also call your plan's customer service line to confirm coverage before you pick up the prescription. This prevents a trip to the pharmacy only to find out you cannot fill it.

What to ask your doctor and pharmacist

Before your doctor prescribes Binosto, ask whether alendronate would work just as well for your condition. If your doctor says Binosto is necessary, ask them to check your insurance coverage or to submit a prior authorization request if your plan requires one.

Ask your pharmacist what your copay will be for Binosto and what it would be for alendronate. Ask whether your plan requires prior authorization and how long that usually takes. If Binosto is not covered, ask the pharmacist to contact your doctor about switching to alendronate or another covered osteoporosis medication.

Frequently Asked Questions

Does Medicare Part A or Part B cover Binosto?

No. Binosto is an oral medication you take at home, so it is not covered by Part A (hospital) or Part B (doctor visits and outpatient services). Only Part D prescription drug plans cover it. If you have a Medigap or Medicare Advantage plan with drug coverage, that plan's Part D component determines whether Binosto is covered.

What if I cannot afford the copay for Binosto?

Ask your doctor whether a generic or lower-cost osteoporosis medication would work for you. If cost remains a barrier, ask your doctor's office whether the drug manufacturer offers a patient information program — many brand-name drugs do. Your pharmacist can also help you find programs that reduce medication costs for people on Medicare.

Can I use a GoodRx coupon or discount card instead of my Medicare insurance?

You cannot use a discount card at the same time as your Medicare Part D coverage. However, you can compare the price your plan charges with the price on a discount card and choose whichever is lower. Tell the pharmacy which payment method you want to use before they process the prescription.

What happens if my plan stops covering Binosto next year?

Plans can change their formularies each year. If Binosto is no longer covered, your plan must notify you before the change takes effect. You can then switch to a different plan during the annual enrollment period or ask your doctor about switching to a covered alternative like alendronate.

Does my Medigap plan cover Binosto?

Medigap plans do not cover prescription drugs. If you have Medigap, you need a separate Part D plan to cover Binosto. If you do not have Part D, you can enroll during the annual enrollment period or within 63 days of losing other drug coverage.