Insurance has denied Evenity

I just read yet again that Forteo and Tymlos are not effective after Prolia.

You might watch Combinations and Sequencing, an online video by Dr. Ben Leder, or check out "Great Bones," a book by Keith McCormick. I watched Leder earlier today, again, but can't remember whether Evenity is a good choice in your situation. So sorry you are going through this!

I don't know how long you were on Prolia or how long you have been off but ask your docs how effective Evenity is after Prolia and if it addresses rebound the way that Reclast does.

I just watched a Dr Keith McCormick video and he said Reclast after Prolia for rebound. He also said don’t stay on Prolia longer than 2 years.

@jduke What is Prolia Rebound? I haven't heard that term before. What is your insurance and what is your age? With the initial denial and the denial on the appeal did your insurance company suggest a substitute for Evenity?

I have Traditional Medicare and Evenity is fully paid for with my plan. Medicare Advantage plans are under a private insurance company such as Aetna or United Health Care and while the cost may be different they do contract with Medicare. For that reason, I believe that if Medicare has approved something then the insurance company where you get your Medicare Advantage Plan has to cover it also. I has a fracture last year which is why my endocrinologist, at Mayo, recommended Evenity.

Which insurance. Also, Amgen has their Safety Net program and one of the criteria one needs to meet to get help via Safety Net is to be denied coverage by your insurance. I'm doing Evenity with Safety Net's assistance. When you talked to Amgen did they mention Safety Net? Did they give a reason that Safety Net couldn't help you?

" However, when romosozumab is given after alendronate, BMD increments in both total hip and spine are significant and substantial. When romosozumab is given after denosumab, BMD increases in the spine and is maintained in the total hip. In both cases, these BMD results are superior to the BMD effect of switching to teriparatide.”
https://www.healio.com/news/endocrinology/20200918/treatment-sequence-influences-romosozumab-effectiveness-in-osteoporosis
I've heard of insurance yielding with effecient efforts of physician offices. Many patients report first denial then approval.
Meanwhile though, the results with alendronate could offer you some protection, without hindering eventual Evenity.

I am on an Advantage plan but Medicare Part B pays for Evenity because it is given in the doctor's office. However I paid $427.60. We'll see what it costs in a new year if I do it again.

I just rewatched Ben Leder MD's video and he says that after a bisphosphonate, Evenity is 1/3 less effective in the spine and 1/2 less effective in the hip.

It is frustrating to see so many studies and provider opinions that all differ somewhat.

The way it was explained to me by my endo, Prolia Rebound is when you stop taking Prolia and the gain you made with Prolia falls away. Prolia is like gum, when it falls away, it takes not only what it added but my bone also. So, within 18 months- 2 yrs of being off Prolia, I went from osteopenia to -4.2 and -4.7. I am 62 and not on medicare but on blue cross blue shield -gold plan. I did do one treatment of reclast. It made me super sick, but little improvement and some worsening. Every doc I've seen since reclast has said that was wrong protocol. Reclast stops bone loss but I don't really have bone to lose, I need to rebuild faster (Evenity) than I'm losing. Radiologist says I'm at 100% fracture rate. Insurance denied and Amgen plans are not a fit, I'm outside the income limits. I've talked to Amgen multiple times and each thing they have tried has been unavailable to me.

yes, said i was outside income limits

docs say i have less than 10 years of independent living left if i don't get evenity. i'll take 2/3 and 1/2 effective, y'know?

Helen,
I, too, am on traditional Medicare and on Evenity which is 100% covered. The cost - $5,000+ for each monthly set of shots!
I am pretty certain that the Advantage plans do not have to follow the traditional Medicare guidelines. As they are private insurance plans, they have their own rules.