Evenity and Medicare - What do plans cover and how much?

Posted by amli65 @amli65, Sep 12, 2022

Medicare B coverage info for Evenity. How much do they pay per month for it. Medicare could not answer the question about cost or the assignment they pay per month. Does anyone know?
The amount would help to see if it would be affordable.

Thank you in advance for your input

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Evenity is covered under Medical, Part B. First you need to meet your insurance company’s deductible, than no cost for the treatment for the rest of the calendar year. Come 2025, you start again to reach your 2025 deductible in that calendar year.

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What if you have original Medicare but no supplemental plan?

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@bonesmcgee

Interesting. I wonder why my doc didn't know that. My doc only told me that it would be under a medical benefit, not an Rx benefit.

I did call my pharmacy and they said each shot is $1000 and are given 2 at a time so it would not be $5000 here in NC.

I'm new at this but Part A and B come automatically with Medicare, but a supplemental plan gives more coverage and in some cases is 'free'.
I thank you for your info which shows I should go with the same supplement you have and would like to know if you're in NC.

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bonesmagee,
I’m not in NC, but the supplements are the same across the country. We have been happy with United Healthcare.
Regarding Evenity infusions, that is covered under Part B, so the bulk of it is covered by Medicare.

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I have Medicare advantage which follows the Medicare part B payouts. I just finished Evenity and had to pay 20% of the drug cost which was $416 a month and was $467 by the 12th shot. It was expensive but I gained 20% bone density in his and spine.

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As others have said, if you have original Medicare with Parta A and B, Evenity injections given on an outpatient basis should be covered by Medicare Part B - at least for now. (It will NOT be covered if self-administered at home.)

That means that Medicare pays 80% after the annual one time Part B deductible ($240 in 2024). You can get a supplement to cover your 20% co-pay.

The Medigap supplement plans are standardized, with the different options identified by letters. A chart summarizing what is covered by the different options can be found at Medicare:
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Compare Medigap Plan Benefits | Medicare
https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits
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And a broader discussion of Medigap supp plans starts at:
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What's Medicare Supplement Insurance (Medigap)? | Medicare
https://www.medicare.gov/health-drug-plans/medigap
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The section on "Get Medigap Costs" gives an overview + a link to a page where you can look for available plans:
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Get Medigap Costs | Medicare
https://www.medicare.gov/health-drug-plans/medigap/basics/costs
Find a Medigap policy that works for you
https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m?year=2024&lang=en
If you talk to an insurance agent or broker, look for someone who is not pushing Medicare Advantage/Part C plans.

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@cat1203

What if you have original Medicare but no supplemental plan?

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If you have original Medicare but no supplemental plan then Medicare pays 80% and you pay 20% (as opposed to being covered by a supplemental plan).

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@susanfalcon52

I am on traditional Medicare. I recently had my 12th injections of Evenity. Because I had them at an infusion center, they were covered under Part B.
100% covered. When I receive the EOB from Medicare explaining what they paid for what and how much, the Evenity bill is heart stopping.
$5,000+. So, in the past year Medicare has paid more than $60,000 for my Evenity treatment. I am very grateful, but still know that Big Pharma is a monster.

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So did you pay $5,000
Or were you saying that was the individual injection cost to Medicare?

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@lbtw

I don’t know if any of you can offer a suggestion — but thought I’d give this group a try. I just started Evenity this past week and it is covered by my current insurance. In August I will be on Medicare and I’m trying to find a drug plan - part D - as I research them — none cover Evenity — with a 17,000+$ cost. Any suggestions. Thanks in advance

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I paid $0.00. Medicare paid $5,000+

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@hopefulheart

So did you pay $5,000
Or were you saying that was the individual injection cost to Medicare?

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I was researching drug coverage — I will be on Medicare soon — I mistaken thought it was under part d but it’s covered under part b — so no problem on coverage.

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@hopefulheart

So did you pay $5,000
Or were you saying that was the individual injection cost to Medicare?

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I paid $0.00. Medicare paid $5,000+.

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