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

@amli65, ummm, I was going to suggest calling Medicare to find out, but it looks like you did that already. I'm hoping members like @cireland @gailb @artscaping @csday @suemer might have some knowledge and Evenity and coverage and costs.

Have you found out anything in the meantime?

Yes I did call Medicare. The doctors office said they couldn’t tell me, however they did give me a CPT code J3111, which Medicare said only means injections of Evenity not the assignment cost.
Any suggestions on how to find out Medicare assignment costs for medications.
Thank you

Good morning @amli65, I am happy to meet you on Connect. Thanks for the introduction @colleenyoung. This is a tough issue, particularly because Evenity is a relatively new product. You may need to do the following:
1. Make sure a pre-approval request has been made by your doctor
2. Find out if Amgen, the company that produces the product, has a preferred "specialty pharmacy."
Here is the phone # for Amgen 800-772-6436. Ask to speak to someone in the patient support group....they are medical professionals, mostly RNs who can
help you.
3. Make sure that Evenity is on the Medicare formulary. If not, ask for a formulary exception.
4. Ask if there is any program or organization that will help you with the copay.
5. If you are on Social Security (SS), you may have to apply for low-income assistance from SS. If you qualify for assistance then that is helpful. If you are denied
by SS then that information can be used to support your application for other assistance from Amgen or a recommended assistance program.
6. Be patient, and follow up frequently. Your doctor may also be asked to submit approval documents clarifying your need for the medication.
7. Make sure the renewal date requirement covers your one year of Evenity. If not, then find out how and when to renew.

Good luck to you. Evenity appears to be a good choice because it both builds and protects the new bone.
I am not an expert at this process. My daughter actually took over for me since she works in a dental surgery environment and knows how to handle insurance situations. However, I am here to help wherever I can.

May you have happiness and the causes of happiness.
Chris

Thank you for the input. I will try all the suggestions. I find it that the medical world, drug co, insurance co, health care office administrators, & Medicare. They all seem to pass the buck, instead of just giving out the info, good or bad at least people would know to make an informed decision.
Thank you again

I followed up on the discussion, and this is the information I received as I understand it:
Medicare Part B does NOT cover Evenity. If there is no cost assignment, it means it is not covered.

A formulary exception has to be filed with your Plan D. This even if the drug is considered a medical expense by commercial policies. That is what a Medicare supervisor told me.

Amgen says it has special assistance for people who have commercial insurance, not Medicare. If you are on Medicare and think your income may qualify you for financial assistance, you can contact the Patient Access Network or the Healthwell Foundation Amgen gave me the names of both of these organizations.

If anyone has found out different information on the issue of Evenity, please share! The other injectable is Forteo. Does anyone have experience with that one? It is a daily injectable, and has a generic, so instead of costing thousands of dollars a month it costs hundreds a month.

@baguette Tymlos is also an injectable and I chose that over Forteo because the dose is adjustable, and I started low and ramped up to minimize side effects.

I talked with Amgen when considering Evenity and was told it was Part B because it is injected in the doctor's office. Unlike Forteo and Tymlos there is no patient assistance program but as you said they can refer to a foundation or two, but at certain times of year the foundations have no funds for this.

I have a Medicare Advantage Plan and Evenity was very expensive for me without help. I qualified for the Tymlos patient assistance (Radius Assist) and have gotten it for free for 18 months.

Thanks for sharing the experience on Tymlos.

I am on traditional Medicare and none of the Plan Ds cover Evenity. Which makes sense because as you note it is administered in a doctor's office. So Medicare Part B would have been the logical place for it to be covered. The Medicare supervisor's comment about applying for a formulary exception with the Plan D company made no sense to me.

I will look into Tymlos.

I think the various manufacturers are helpful on insurance and funding issues 🙂

Together with Tymlos gives you a personal representative who you can call directly. You can google it!

I am getting Evenity monthly now. Today I’ll receive my 8th set of injections. I chose Evenity because the other option would have cost me out of pocket $20k for the year. I didn’t look up the cost but it is negligible. The injections are not fun and I have to get my lab work done in advance to check my calcium levels to ensure that I can get them. I got Prolia for 5 years before this. I can’t know, of course, how these are working but I seem to be fine. I hike in the hilly woods nearby and lead an active life without fear. So, I think It’s a good choice.

Medicare Part B DOES cover Evenity because it is administered in the doctors office! I know because I’m getting Evenity injections now with minimal costs or hassle. Interesting how misinformation is spread from allegedly reliable sources.