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Evenity Insurance Approval
I am 56 years old and have a T score of -3.2 (lumbar) and a previous compression fracture (mild) in my L1. My insurance company (Aetna) has denied my doctor's recommendation to begin Evenity treatment. When I read their Clinical Policy Bulletin on Evenity (https://www.aetna.com/cpb/medical/data/900_999/0954.html), it seems that I qualify based on my T score alone. I have spent many fruitless hours on the phone with Aetna trying to understand why they are denying coverage. My doctor is appealing the decision. Has anyone else found themselves in this situation, and are there any tricks that might help me/my doctor gain approval?
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@mblatcher,
My doc qualified me first for Tymlos, pretty much based on having vertebral fracture(s), and then for Evenity because of my many adverse reactions to Tymlos. I think both meds were approved quickly and without problems or appeals.
Insurance companies are unwise not to cover/assist in the costs for these meds - hospital stays, rehab if necessary and possible debilitation are far more expensive than the drugs. An ounce of prevention…
I wish you the best in your quest for approval. Cheers!
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2 ReactionsIn my experience, the insurer explains the reason - if not to you, to your doctor. Yes, it is frustrating.
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1 ReactionSometimes when the doctor appeals, it leads to a peer to peer review, where your doctor gets to speak with an insurance doctor. These are usually helpful. If you’re not given this opportunity, look into your insurance omsbudsman, they are usually well versed in negotiating with insurance companies
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1 ReactionSorry you are going through this. It's so frustrating. I've read that most appeals are successful so I think that's the best you can do at this point.
I am on Evenity right now after trying Fosamax, Tymlos, and generic Forteo. I fractured after five years on Fosamax and was started on Tymlos. The insurance company then revoked my pre-authorization for Tymlos and forced me onto generic teriparatide.
I had side effects from teriparatide so that may have played a role in them approving the Evenity. I think a lot of it is in your doctor's hands. I have a great endocrinologist who specializes in osteoporosis and is apparently skilled in getting approval as she had approval within days when I was expected it to take weeks.
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2 ReactionsMy Endo said the T score (-3.5) didn't matter to insurance, but that I jumped to the top of the list with having had compression fracture. don't know for sure because I chose not to go on it for now. good luck
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2 ReactionsTo follow up…. My healthcare company states the following “Your plan only covers this drug if A) You have tried and failed treatment with Prolia and B) It did not work well for
you. We have denied your request because you did not try and fail Prolia, had a bad side effect, or
you do not have a medical reason not to take it. “
I’m pretty new to this, but everything I’ve been told by my doctors and have read, states that with severe osteoporosis in someone my age, an anabolic drug (Evenity/Tymlos/Forteo) should be tried before Prolia. My rheumatologist was very clear that she wouldn’t use Prolia in a 56 year old without first trying an anabolic. I’ve also read that anabolics are less effective when not used as a first line treatment. I’m so frustrated and confused. My 91 year old mother just fell and broke her hip. They have diagnosed osteoporosis (very common at that age I’m sure). But I’m getting to see first hand what that looks like and it’s not pretty.