Insurance company is denying Evenity

@osteopatient2026
Spine is -2.7 and hips are -2.0

@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.

I 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.

I 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.

@rudysmom What about teriparatide (Forteo)? It is now available in generic form, so it is less expensive for the insurance company than Evenity but it is also an anabolic bone-building drug. Maybe insurance would approve this?

I would ask my doctor about teriparatide, and I would self-pay if insurance denied that and assuming that I could swing the cost, which many can not. Teriparatide costs about $850 per month via self-pay and you need to do it for 2 years. But you only have one set of bones and, as you said, anabolic bone-building drugs are not as effective after taking denosumab (brand Prolia) so there is no going back once you get far down the Prolia path.

A long shot, but there was one person on this site who got a big discount from the drug company when she did self-pay of Evenity (romosozumab) after insurance denial. Others have said that there are no discounts if you are on Medicare and I assume that includes Medicare Advantage if that is how you have your Blue Cross Blue Shield insurance. Some bone experts are now saying it is only needed to take Evenity for 6 months instead of the full year so that can help reduce cost, but it will still be a huge financial investment. So investigate that as well (Dr. Benjamin Leder for example.)
https://www.costplusdrugs.com/medications/teriparatide-560-mcg_2_24ml-solution-pen-injector-2_24/

@rudysmom
That could/would have a big factor in why you might nor get Tymlos or Evenity

@osteopatient2026
It’s just crazy that you either need to fracture or have worse numbers to get a drug that can help build bone. My hope was that if I did Evenity I’d get pushed back into osteopenia and then do a year of a biophosonate and hopefully have a drug holiday. If this doesn’t work out then I’m going to contact midi health and look into HRT. Maybe that’ll help keep things stable for a while. 🤷🏻‍♀️

@kfhoz
It was weird that Dr only suggested Evenity. Never mentioned Forteo or Tylmos. I’m going to wait and see what they say when they call me back. If they’re adamant about Prolia I’ll go elsewhere. Or see if I can get a break financially with the company themselves.