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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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@osteopatient2026
Spine is -2.7 and hips are -2.0
My spine is -3.6 (neck -3.8) and I was denied Evenity.
My bone specialist initiated an appeal for me due to my "Severe Osteoporosis" and low blood pressure (daily injections like Tymlos & Forteo lower BP and can frequently cause palpitations, which I have a history of).
Unfortunately, your insurance most likely denied Evenity because your DXA results are fortunately not so bad and bisphosponates like Prolia, Fosamax, etc. are the typical protocol for your score.
None of these medications are without side effect nor possible adverse reactions.
You may ask your provider to help you with an appeal, but if it's denied once again, you may just have to try Prolia and prove that it's not indicated for you.
I wish you the best with pursuing what you desire.
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2 ReactionsMy understanding is that as long as you tried one of the others first and could not tolerate it you would be able to do evenity. Did your doctor mention that you already tried another drug? If not maybe your Endo can reapply for the evenity with that added.
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1 ReactionIs your doctor advocating for you with the insurance company? I am so sorry that you are being treated like this. How far up the food chain did you go? What is their dispute process?
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2 Reactions@samclembeau
I’m not sure. I’m going to say she didn’t. The office called me a couple weeks ago asking if the infusion center got ahold of me and set up appointment. I said no that I had received 2 denials from BCBS and that I called the infusion center and left a message stating I tried Fosomax and had a reaction and maybe they could inform insurance company of that. So Dr office said they were sending my script to another infusion center closer to me. I think that was 2 weeks ago. Then yesterday I got the phone call saying insurance wants me to do Prolia.
@gravity3
I have to call Dr office back today and ask. Hopefully I can talk to someone else in the office. Person who called me yesterday wasn’t very friendly. Just kept saying insurance company wants me to do Prolia and need to make appointment.
@rudysmom
A lot of this communication should be between your doctor and insurance company…it is there responsibility
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2 ReactionsTry filing an appeal. There is a form. Ask your insurance for the form.
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1 ReactionIf you and your doctor appeal your request against Prolia, include the chart documentation of your reaction should be included as proof as to why you are appealing for Evenity. The insurance companies use vast clinical studies to determine the next steps for care. Not everyone fits into the protocol is so you have to prove your point with facts. Best wishes for you!
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2 ReactionsI have experienced denials from United Health Care (UHC) for over 9 months. I recommend that you first appeal the decision with BCBS and request your endocrinologist to assist you with the appeal. There are guidelines for receiving approval for anabolic osteoporosis drugs but you can still persist in your appeals. My t- score is -3.7 but I have never experienced a fracture despite many accidents throughout the years. After your initial appeal, prepare a report for Medicare and submit it to Medicare directly if the denials continue. You should expect delays and non- responses to your communication with BCBS since that is the norm. Do not let this deter you in your pursuit of drug approval. After 2 denials, submit your complaint to Medicare directly but include specific details. All Medicare Advantage plans are required to respond to you within 24-48 hours and they will after you file your complaint with Medicare. If you receive further denials, your next step is to request an internal peer to peer review with your endocrinologist. If your endocrinologist refuses to participate then find a new endocrinologist willing to fight with you against BCBS. After they refuse or ignore your request then request an outside independent review from an endocrinologist via the Medicare contractor C2C Innovated Solutions. Your appeal will be forwarded to them by Medicare and BCBS. If you are denied by C2C then your appeal can be referred to the Office Of Medicare Hearings And Appeals (OMHA) court for an expedited review of the appeal. The court refused to approve my request for an expedited review but proceeded with the 90 day review. I never heard from the court again but a couple of weeks later I received a letter from UHC approving my request claim for Tymlos. No explanation other than 3 sentences stating they appreciated me bringing this to their attention and after review, I am now approved. I started Tymlos on 07/20/2026.This process is quite arduous but worth it. Please note that Tymlos is over $7000/month but you are protected by the catastrophic drug limit by Medicare law limiting your exposure of $2100/year. Do not let BCBS cheat you should you gain approval. Good luck and be persistent.