Insurance denied Evenity

Posted by rudysmom @rudysmom, May 13 9:54am

Well just received an email that my BCBS denied my request for Evenity. My Dr said this might happen as they usually want you to have a fracture first for these bone building meds. So, it’s better for me to fracture and cost my insurance company a ridiculous amount of money rather than give me the med that can prevent it. Makes sense. Not.

I had asked what my other options would be when we discussed that it could be denied. I tried Fosomax when I had osteopenia and I had severe back pain. So Biophosphonates are out. That leaves me with Reclast and Prolia which I’m only 61 and really don’t want to start on that. So I guess my only option is Reclast. My spine is -2.7 and hips are -2.0.

I was diagnosed in February and just got my head wrapped around all this and was finally at peace with the decision to start Evenity. Hope they will appeal. I feel like since my numbers aren’t that severe yet, that Evenity would have given me a big push back to osteopenia.

I know the office staff told me the Dr doesn’t prescribe HRT. Which I can get from my Gynecologist. I have an appointment with them next month. Maybe I need to look more into that.

This is all so frustrating.

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

gravity3 | @gravity3 | May 13 10:27am

What about tymlos or forteo

rudysmom | @rudysmom | May 13 10:40am

In reply to @gravity3 "What about tymlos or forteo" + (show)

@gravity3
I’m going to assume my insurance will deny those too, but I will ask. Since I can’t tolerate Fosomax maybe they need to appeal it stating this.

Helen, Volunteer Mentor | @naturegirl5 | May 13 11:13am

In reply to @rudysmom "@gravity3 I’m going to assume my insurance will deny those too, but I will ask. Since..." + (show)

@rudysmom You can also ask your doctor to appeal the BCBS denial for Evenity. Sometimes these appeals work. In your place if my doctor felt that Evenity is the preferred treatment especially since you had intolerable side effects with Fosamax then I'd ask for the appeal.

By the way, I did have a fracture and my endocrinologist prescribed Evenity. Medicare Traditional plus my Medicare supplement covered all of the cost. I had no side effects.

I wish you success with this appeal.

dianat | @dianat | May 13 6:45pm

I agree about asking your doctor to appeal. I’m surprised BCBS denied because I have Florida Blue and it’s covered. Good luck!

jeanvarney | @jeanvarney | May 13 6:55pm

Definitely ask your doctor to appeal. United Healthcare denied me Evenity in 2021 but my doctor appealed and won. I've since changed to Cigna who approved a second round of Evenity last month in just a day ... Good luck!

kfhoz | @kfhoz | May 14 12:32pm

In reply to @rudysmom "@gravity3 I’m going to assume my insurance will deny those too, but I will ask. Since..." + (show)

@rudysmom Sequencing of a PTH such as teriparatide (Forteo) before Evenity is supposed to be one of the most successful approaches. In your place I would try for teriparatide now in the hopes of following with Evenity in 2 years.

There are quite a few doctor & researcher videos on YouTube who talk about the order or sequencing of OP meds. Dr. Doug Lucas has a recent one for example. That I just linked on another discussion thread. If you search on "Osteoporosis Treatment: Best Order for Medications Explained" you should also find it.

rudysmom | @rudysmom | May 14 3:10pm

In reply to @kfhoz "@rudysmom Sequencing of a PTH such as teriparatide (Forteo) before Evenity is supposed to be one..." + (show)

@kfhoz
Thanks I’ll look into it. Not sure why Dr suggested Evenity first, but if my insurance denied Evenity I’m sure it will deny that as well. Which is odd because I have really good insurance.

shorty321 | @shorty321 | May 15 6:05am

I have UHC insurance (ACA Marketplace plan). Evenity was approved even though I had no fractures within the past twenty five years and never took any prior osteoporosis medications.

Normally, after you finish your course of Evenity, you would lock in the gains with a Biophosphonate. If you can’t take Biophosphonates, how would you lock in the bone density gains? You lose all of your bone density gains from taking Evenity within a year if you don’t go on another medication soon after ending your round of Evenity injections.