Insurance has denied Evenity

Evenity is covered by Medicare B even if you have an Advantage Plan because it is given in the office. However, I had to pay 20%. @susanfalcon52 do you have a supplement to your Medicare? That might explain your 100% coverage. Those of us on Advantage Plans get the coverage that you would get without a supplement, which is 80%. Our Advantage plans aren't involved at all.

Windyshores,
That was a fast response. Early morning must be when we go on this site. Yes, I do have a supplement to my Medicare. But, Medicare Part B covers it because I get it in an infusion center.
It is covered at 100%.

@susanfalcon52 I'll have to check but I thought that if Medicare approves coverage then Medicare Advantage must also cover. The cost will be different but coverage is not supposed to be denied by Medicare Advantage. So, for instance, if Traditional Medicare covers Evenity then Medicare Advantage is supposed to cover Evenity also. But the cost to the patient will be under the Medicare Advantage private insurance company rules. Private insurance does have their own rules but they do contract with the federal government's Medicare program. I'll check on that.

You insist (and have insisted previously) that Medicare Part B pays 100% for your Evenity at an infusion center. Yet no one on this site appears to agrees because it is generally understood that Medicare pays only for 80% under Part B except for some preventive services like vaccines.

Perhaps you will be kind enough to scan and attach a copy of whatever you receive that indicates to you that it is Medicare Part B that pays 100%. Maybe that is the only way to try to sort this out and prevent misunderstanding by those looking to this site for reliable information.

Hi jduke, I would still make the point that the disaster of multiple fractures that sometimes occurs after stopping Prolia does not require a year or more to happen. People sometimes report it happening within 2-4 months of missing a Prolia shot. This may be what you are describing with it taking away your "own" bone not just the bone that Prolia helped you build. I'm just adding that whatever happens it has not been clearly described in any research I've seen that the sudden fractures are fully accounted for by the amount of general bone loss in DXA scores.

I'm sorry you lost so much bone in 2 years. I totally agree with you wanting to try Evenity. Doctors and insurance tried to push me to take something else other than Evenity but I wanted to take the med that would give me the most bone growth possible. All the meds have serious possible side effects - why take a med that doesn't build as much bone if you can take one that builds more? WindyShores has reminded me there are other considerations such as Tymlos allowing control of the dosage but in general Evenity is the one that makes the most sense to me. I lucked out and got Evenity thru the Safety Net program (that is if you call 6 months of struggling with doctors to get Evenity luck). Anyway I was about to pay out of pocket to take Evenity when I got Safety Net approval. I don't know your financial situation and no one wants to pay that much but it might be worth it if it gives you better odds of building some bone and not fracturing. Also if your hips have poor density doctors like Ben Leder mention that Evenity is a safer choice than Forteo and Tymlos.

windyshores,
Yes, I do have a supplement which does cover the balance - thus 100% covered. I’m sorry if I wasn’t clear. I didn’t intend yo mislead.

Rjd,
Please see my response to
Windyshores politely worded question.

I think part of the confusion lies in people trying to distinguish that Evenity is covered by Part B and not Part D. Being n Part B makes it eligible to be covered fully by Medicare plus a supplement. Good luck trying to get that under Part D.

I just want to add that even though it was covered by Part B/Medicare not my Advantage Plan, I still needed prior authorization with my Medicare Advantage plan.

Small point on something I learned today: my endo told me that Tymlos does not affect cortical bone density negatively the way Forteo does. This applies to the femur neck that is my biggest worry so I was relieved. I wonder why we aren't told this when deciding on meds. Evenity is good with hips, more than either of the other two.

Prolia works by preventing the cells that break down bone from forming, from developing and from living as long. Your body developes a great resevoir of cells waiting to transition and waiting to finish transitioning. When you stop Prolia, when anyone stops prolia these cells resurge to far beyond baseline, unless you take a medication to stop them.
Jduke, I think you need combination therapy https://www.frontiersin.org/articles/10.3389/fphar.2020.607017/full
It seems like you don't have any bone left, but you do. An antiresorptive is crucial to avoid fractures. You also need to rebuild bone. I'd want Tymlos. Obviously you can't use reclast. I'd choose risidronate with Tymlos. I'd choose that combination over Evenity.
Some medical offices are good at reversing insurance decisions. Some know how, some don't. Some are willing to make the effort, some aren't.
You might press your endocrinologist's office to fight for you, or change offices In the meanwhile you might see if you can get approved for Tymlos and start risidronate or alendronate.
I'm sorry you are in this situation and wish you the best luck.