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Insurance company is denying Evenity
I just got a call from my Dr stating my insurance company BCBS is denying Evenity. They want me to do Prolia first. I told the person who called me that Prolia is the one drug I didn’t want to do. That there is research showing if I do that first the Evenity won’t be as effective, also that Prolia rebounds quickly. She agreed with me, but this is what insurance company wants done first. I said it’s ridiculous they get to dictate my healthcare. Again she agreed. She told me to think about it and call them back.
I was diagnosed back in February with a -2.7 in spine. Hips are still in osteopenia, don’t remember those numbers. I decided in May to go on Evenity and it’s been a battle ever since. A couple years ago I tried Fosomax when I was still in osteopenia and had reaction of severe pain in my right hip, so I stopped taking it after 3 weeks. I’m afraid if I can’t tolerate Fosomax I’m not going to tolerate Prolia. Not sure what to do at this point. 😣
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Is there a way you can contest that decision?
I’m going to try. I would think my Dr would. When I met her at first appointment she was against Prolia now her tune has changed. Obviously she’s not looking out for my best interest.
You need to get your doctor to write a “letter of medical necessity” directly to the insurance company…it helps if your doctor is a specialist like an endocrinologist or rheumatologist…ask for a referral. If you have had a previous fracture possibly due to your OP …I think I posted somewhere what I did in November of 2025. Hope this helps.
If your BMD, FRAX score and T scores are in the osteoporosis range moderate to severe…you should qualify…however BCBS may have changed their requirements since 2025.
Have you called the makers of Evenity? They may help with the costs without insurance. Worth a try to see how they can help.
Amgen SupportPlus at 1-866-264-2778
@osteopatient2026
I am seeing an Endocrinologist. She did tell me that insurance prefers you have a fracture before they ok Evenity. Which is crazy. I haven’t had any fractures. 🤞🏻I’m going to call insurance myself tomorrow and see what they say. Then I’ll call Dr back tell them to do a peer to peer review or what you suggested. I don’t understand why she isn’t suggesting something other than Prolia? Just because the insurance said so?
@oknowwhatpixie
No. Didn’t know that was an option. Thank you. I’ll give them a call.
@rudysmom
What are your T Scores
@rudysmom
Be careful what information you give out …you could end up saying something unintentionally that could paint you into a corner
@rudysmom
A fracture, very low tscores all factor into the treatment you qualify for. Why I asked what your BMD and tscores are.
You said in an earlier post your spine was “-2.7 in spine” if that’s correct it doesn’t put you in the moderate to severe osteoporosis that would warrant Evenity, Tymlos etc.
You are just in the osteoporosis range. Tymlos Evenity and Forteo are powerful drugs that some doctors will try to prescribe even with border line osteoporosis …age and other factors come into play as well.
@rudysmom
Worth a shot as other meds have support options. But definitely ask your Dr to followup as to what insurance would need to get approved. Just keep pushing at different channels.
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