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

Thank you for chiming in here. This sounds like great news for me. As far as you know are there any other stipulations that apply in order to have MediCare Part B cover these injections (other than the doctor's billing department bill Part B and not the RX plan). Things like evidence of prior fracture, doctor submitting a request for exception, etc etc....ANY AND ALL information is so greatly appreciated ! We certainly have to be our own advocates and I'm so happy to have found this whole community of support !

@berniebrooks3, As someone else mentioned, you have to get the injections in an infusion center. Before my scheduled start date, I was able to confirm that these treatments would be covered at 100%. (I didn't end up starting, but I got the info I was seeking). Good luck!

My personal experience . . .

Tymlos is administered personally at home, partially covered with a Part D co-pay. Evenity is administered in a doc’s office, again with a co-pay. Reclast is administered in an infusion center and, as I remember, there was no co-pay.

I’m glad to hear some of us are receiving these treatments with zero out-of-pocket dollars as the costs can really add up. At least with Tymlos, once the Part D coverage reaches the “donut hole” the price goes wayyyy down. For Evenity, the monthly co-pay was not horrible and remained steady throughout the treatment.

I don’t know the criteria as far as previous frax, etc for whether or not that affects the costs. I questioned the insurance company about the validity of Evenity being a “medical service” and not a script and was told I was billed correctly.

Cheers, all!

Medicare Part B covered my Evenity at 100%. I had the injections at an infusion center.

I am so grateful to everyone in this forum for clearing up how to deal with the expense of these medications because they have a hefty price. Thank you all.

The only other thing though is that my endocrinologists both say I will always have to be on these drugs forever once I start them. Is anyone else here concerned about that??

edwinabutterfly,
I’m unsure about this myself. I had 12 months of Evenity snd then an infusion of Reclast. No one has discussed with me what the next step is. I’m assuming that I will have another infusion of Reclast in a year or so. Then another. Then maybe a drug holiday. ????
I’m going through this process and the Evenity was a success.
My problem is my endocrinologist and my rheumatologist. Useless.
Neither have reached out to me about my dexa or anything else. They both only seem to have a basic knowledge of osteoporosis and treat the osteoporosis patients like a side hustle in their practice. When I asked the rheumatologist about ordering blood work, he had to look up the tests. He had never heard of them.
So, I have been very fortunate in that I had minimal side effects from drugs and the Evenity did its job. I just wish that I had more engagement from doctors.

For those on traditional Medicare, if there is a supplement, the co-pay should be 100% covered.

I had Tymlos, which I couldn’t tolerate and Evenity. Prior to both meds, I had Reclast.

This past Friday, I had a second opinion consult with a second rheumatologist about my lifetime OP treatment plan. I couldn’t believe the difference in my visits from one doc to another. My first doc was, as many have stated, useless - I feel I know more about OP than he does. The second (and my new) rheumatologist is very much the educator. He not only listened to my questions and concerns, but he also gave me so much info and ordered a baseline CTX; my first doc told me that no tests were necessary except for a DEXA (which doesn’t always tell the whole story). He also thought it would be a good idea to have baseline x-rays of my femurs to monitor any changes.

I too am enjoying the benefits of Evenity and hope to ride the maintenance carousel for a bit. I’ll know this week about whether or not I can have at least one more Reclast infusion (lifetime number is high for me). This doc agreed that perhaps Prolia wasn’t the best choice for me, right now, as I am not even 70 and don’t want to think about being tied to Prolia for the long haul. It seems as though the problem with Reclast is the possibility of ONJ and spontaneous femur fractures.

I am still confused about the coverage for Evenity with Medicare Part B insurance. I need to look into the charges associated with Evenity injections as my monthly charge for them was hefty.

Thanks, all, for providing information to help me and others through this maze of treatments. Cheers!

beanieone,
Are you on Traditional Medicare? And, paying for a supplement? If so, I don’t understand why you have a cost to you.