Insurance denied Evenity

@lourdita15 My fracture was in the sacrum in the lower back and due to osteoporosis. I was 72 years. old at the time the fracture was identified. It's now healed and I have had no other fractures.

@naturegirl5 thank you. I believe that would
Definitely be an osteoporosis fracture.
So many different opinions from different doctors.

@lourdita15 So much recent research says to start with an anabolic bone-building drug, not first an anti-resorptive for best results. There are many recent YouTube videos with prominent OP doctors and researches about this "sequencing" or "order". Some of those have references to research papers. I have linked just one at the bottom of this post.

See below for Fragility Fracture definition from IOF. If you meet that criteria, (e.g. you did not have a car crash or fall off a ladder) then you can try showing that to your Endo. If your doctor did not call your breaks osteoporosis fractures then the insurance company is not likely to approve an anabolic. Some people have done self-pay in those situations and were able to get reduced prices from the drug company. But you may need a doctor who is on your side.

In your situation I would try to get references like the below in front of my current endo. At the same time I would start the long and challenging process of finding another doctor.

International Osteoporosis Foundation IOF
https://www.osteoporosis.foundation/health-professionals/fragility-fractures
EXCERPT: "Fragility fractures are the clinical outcome of osteoporosis. These fractures arise following an event which would otherwise not be expected to result in a fracture. Fractures occurring in a setting of low-level or low-energy trauma, defined as falling from standing height or less, are usually considered as osteoporotic [1]. However, individuals with osteoporosis compared to healthy individuals, suffer fractures from high-energy trauma at a greater frequency [2]. As such, osteoporosis fracture sites are now more and more characterised by their association with low bone mineral density (BMD) and increasing incidence with age, after the age of 50 years [3]. "

And another on an NIH site:
https://www.ncbi.nlm.nih.gov/books/NBK543829/
EXCERPT: "Fragility fractures occur as a result of “low energy trauma”, often from a fall from standing height or less, that would not normally result in a fracture"

Strategies for Bone Medications with Dr. Benjamin Leder. Dr. Benjamin Leder received his medical degree from Harvard Medical School and completed his Internal Medicine Residency and Endocrine Fellowship at Massachusetts General Hospital, where he has remained ever since. His current position is Professor of Medicine at Harvard Medical School.

Thank you, Believe me, I have done quite a bit of research on this. My endo was my last visit since I've been to 3 rheumatologist and not one agreed on the same. I've been told to start on Fosomax, Prolia and another asked me what I wanted to take, I was leaning into evenity but the insurance didn't cover - although the rheumatologist thought they would because he did label my fractures due to osteoporosis, family history and lie Dexa. I will be getting a new insurance In July so was going to wait and resend for evenity but then my endo tells me differently so you start wondering who is correct. My dentist and my cardiologist said no to all the osteo drugs. My orthopedic surgeon said no to Prolia. I'm sure you can understand my frustrations

@lourdita15 why did your dentist and cardio say no to the osteo drugs? Do you have dental and heart issues? Just curious as I am getting ready to start Tymlos.

They don't believe in them. They say I'm too young (63) to start with those meds.
My cardiologist doesn't like the black box on evenity. I have not had. A heart attack or stroke. I do have family history. I have gum disease which is co trolees
By quartlery cleanings instead of yearly. But my dentist says he has had a few
Clients with problems
Because of alendronate.

@lourdita15
I am 65 and have an L5 compression fracture. My endo said with my T scores (lumbar is -3.4) bone builder is a must. Not thrilled with either but he was pretty adimate that I need them. I trust him so I am going to start Tymlos in a few weeks.

Well my BCBS denied my Dr’s request for Evenity, again. Dr appealed the first denial. Insurance reasoning was: already used. Umm, nope. Now this denials reasoning is: no medical necessity. Good grief! I have OP. Not sure what they deem medically necessary. 🤦🏻‍♀️

May I ask what your T-scores are?

@rudysmom,

My approvals for both Tymlos and Evenity seemed to be no brainers: Because I had tried, and failed with, oral meds, Reclast was prescribed and approved many times prior to Tymlos or Evenity. My rheumatologist told me that there should be no problems with Tymlos or Evenity due to the number of compression fractures I've had . . . that seemed to be the magic word, "fracture". The doc prescribed Tymlos first, which I did not tolerate, and then Evenity. The approvals came pretty quickly for all of the meds. There is also a "chain of command" for the order in which these OP drugs are taken.

There's always a chance that insurance providers are "cracking down" on docs using these drugs often and prior to giving the oral route a try.

Sad to hear that, as of now, these widely-prescribed meds haven't been approved for you. Hoping you find the outcome that works best for you.

Cheers!