Evenity denial by empoloyer-sponsored insurance following hip fracture

Posted by bluemoray @bluemoray, Feb 7 1:57pm

My employer sponsored insurance has denied Evenity even though I had a severe osteoporotic fracture (femoral neck fracture) at 60. My health care team has stated I need an anabolic drug. I can’t wait 5 years until I’m eligible for Medicare to start Evenity and cannot afford US Evenity prices. I’m not a candidate for Fortes or Tymlos. I’ve also called Amgen and their support programs only cover significantly lower income individuals. Oddly enough, I work in Pharma and my employer has indicated that it cannot influence what meds its Pharmacy Benefit Manager includes in the formulary for the company’s plan. Does anyone know whether that’s true? I’ve seen information suggesting it is not. Does anyone have experience with being treated in Canada at cash prices, which look more affordable even if I would travel there every month?

Interested in more discussions like this? Go to the Osteoporosis & Bone Health Support Group.

njx58 | @njx58 | Feb 7 3:56pm

Sometimes you can have your doctor appeal the decision by sending a "letter of necessity" to the insurer. Your employer can't do anything.

Is the insurer not covering Evenity at all? Or, are they saying you have to try some other drug first? That's not uncommon with osteoporosis. They're always pushing Prolia because it's cheaper.

oopsiedaisy | @oopsiedaisy | Feb 7 6:33pm

I recently learned that the majority of denials are overturned on appeal so I would definitely try appealing the denial.

Justin McClanahan, Moderator | @JustinMcClanahan | Feb 20 8:46am

@bluemoray, have you had a chance to see the suggestions from @oopsiedaisy and @njk58 on asking your provider to file an appeal to your insurer? Is this something you have already tried?