1. < Osteoporosis & Bone Health

Medicare B coverage of Evenity

Posted by amli65 @amli65, Sep 12, 2022

Medicare B coverage info for Evenity. How much do they pay per month for it. Medicare could not answer the question about cost or the assignment they pay per month. Does anyone know?
The amount would help to see if it would be affordable.

Thank you in advance for your input

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baguette | @baguette | Jan 12, 2023
In reply to @solveigsp "Medicare Part B DOES cover Evenity because it is administered in the doctors office! I know..." + (show)
@solveigsp

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.

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Wow! I spent 45 minutes on the phone with Medicare to get the information that I shared here. How disheartening to hear that the information was wrong. I guess it's like talking to the IRS. They will answer your questions but not guarantee that their information is correct. I too originally thought Medicare would cover Evenity because it is a medical expense (i.e., administered in the doctor's office) but was unwilling to order it because Medicare wouldn't tell me the cost. That is how I got the information that there was no cost listed because there is no coverage.

How bizarre. Thanks for sharing your experience.

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1 reply
solveigsp | @solveigsp | Jan 12, 2023
In reply to @artscaping "Good morning @amli65, I am happy to meet you on Connect. Thanks for the introduction @colleenyoung...." + (show)
@artscaping

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

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This answer is al wrong! EVENITY IS COVERED UNDER MEDICARE PART B BECAUSE IT IS ADMINISTERED IN THE DOCTOR’S OFFICE! I am getting these injections now and it was NO hassle and costs almost nothing for me. Some of the advisors out there are reps of the Medicare Advantage private insurance industry that I do not trust. Be careful who you listen to.

REPLY
1 reply
Moderator
Colleen Young, Connect Director | @colleenyoung | Jan 12, 2023
In reply to @solveigsp "This answer is al wrong! EVENITY IS COVERED UNDER MEDICARE PART B BECAUSE IT IS ADMINISTERED..." + (show)
@solveigsp

This answer is al wrong! EVENITY IS COVERED UNDER MEDICARE PART B BECAUSE IT IS ADMINISTERED IN THE DOCTOR’S OFFICE! I am getting these injections now and it was NO hassle and costs almost nothing for me. Some of the advisors out there are reps of the Medicare Advantage private insurance industry that I do not trust. Be careful who you listen to.

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@solveigsp, thank you for adding your experience with Evenity and Medicare. You're right that one should be careful who they listen to.

@artscaping's response above states "Make sure that Evenity is on the Medicare formulary. If not, ask for a formulary exception." This is always good advice when considering a drug that is relatively new to the market.

@baguette, the information you received from the representative may have been correct at the time you called. Hearing the encouraging response from @solveigsp, perhaps you should ask again.

Thanks again, Solveigsp.

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dlmdinia | @dlmdinia | Jan 12, 2023
In reply to @solveigsp "Medicare Part B DOES cover Evenity because it is administered in the doctors office! I know..." + (show)
@solveigsp

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.

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Is yours a Medicare Part B supplement? There is a difference. My Part B supplement is with Wellmart Blue Cross Blue Shield. The plan you pick will determine what gets paid.

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dianestanley | @dianestanley | Jan 12, 2023
In reply to @colleenyoung "@amli65, ummm, I was going to suggest calling Medicare to find out, but it looks like..." + (show)
@colleenyoung

@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?

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I am on Evenity. I had the same problem as you when I had first checked on this drug. Everywhere I had called: No one knew how much I would be paying. I believe that my doctor had to get approval for this drug and it had to be given at an oncologists office. My doctor's office told me that they could not give me the shot in their office that it had to be done in another facility. I also believe the requirements for this shot was that you had to have a prior broken bone especially in your back. I have a Burst Compression Lumbar I Fracture and then I found out that I had Osteoporosis. I was a No. 1 candidate for another break. I have regular Medicare, Med B, a Medicare Supplement, and RX insurance. I took a chance and do not have to pay anything. But you are correct, no one could give me any estimate on the cost of this medicine. Evenity is making me stronger, I can feel it. I hope to be able to get the back surgery this year that my surgeon said he hesitated to do due to my Osteoporosis. I will be getting my 6th shot and have had no problems.

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2 replies
dianestanley | @dianestanley | Jan 12, 2023

I am taking Evenity shots also. I have Medicare, Medicare Part B, Medicare Supplement and an RX plan. I had broken my back in 2021 and could not get surgery due to weak bones. I believe you have to get approval for this drug. My understanding was that if Medicare paid and you had Part B, most of the shot would be picked up if you met the requirements. Anything left may be picked up by the Medicare Supp.

REPLY
dianestanley | @dianestanley | Jan 12, 2023
In reply to @baguette "Wow! I spent 45 minutes on the phone with Medicare to get the information that I..." + (show)
@baguette

Wow! I spent 45 minutes on the phone with Medicare to get the information that I shared here. How disheartening to hear that the information was wrong. I guess it's like talking to the IRS. They will answer your questions but not guarantee that their information is correct. I too originally thought Medicare would cover Evenity because it is a medical expense (i.e., administered in the doctor's office) but was unwilling to order it because Medicare wouldn't tell me the cost. That is how I got the information that there was no cost listed because there is no coverage.

How bizarre. Thanks for sharing your experience.

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I could not get a definite answer either. My Evenity is administered at an oncology office. My RX did not cover Evenity either. I have Medicare, Medicare Part B, Medicare Supplement and RX Coverage. Medicare, Medicare Part B and my Med Supplement are picking up my expense.

REPLY
baguette | @baguette | Jan 12, 2023
In reply to @dianestanley "I am on Evenity. I had the same problem as you when I had first checked..." + (show)
@dianestanley

I am on Evenity. I had the same problem as you when I had first checked on this drug. Everywhere I had called: No one knew how much I would be paying. I believe that my doctor had to get approval for this drug and it had to be given at an oncologists office. My doctor's office told me that they could not give me the shot in their office that it had to be done in another facility. I also believe the requirements for this shot was that you had to have a prior broken bone especially in your back. I have a Burst Compression Lumbar I Fracture and then I found out that I had Osteoporosis. I was a No. 1 candidate for another break. I have regular Medicare, Med B, a Medicare Supplement, and RX insurance. I took a chance and do not have to pay anything. But you are correct, no one could give me any estimate on the cost of this medicine. Evenity is making me stronger, I can feel it. I hope to be able to get the back surgery this year that my surgeon said he hesitated to do due to my Osteoporosis. I will be getting my 6th shot and have had no problems.

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Thanks for sharing your experience. Glad it worked out that you didn't have to pay anything after the leap of faith agreeing to the drug without knowing cost.

I do not have a broken bone yet so sounds like I can't get Evenity anyway. I preferred a monthly injection instead of a daily that I did myself. I don't understand the logic of waiting until someone who has been DX'd with severe osteoporosis breaks a bone before gaining access to a drug known to help greatly in addressing the disease.

Good luck with your treatment. That's great that you can feel the drug making you stronger.

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2 replies
kolika | @kolika | Jan 13, 2023
In reply to @solveigsp "Medicare Part B DOES cover Evenity because it is administered in the doctors office! I know..." + (show)
@solveigsp

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.

Jump to this post

Hello Solveigsp --- So happy to hear positive first hand information. My doctor is in the process of ordering this for me as I have dropped into the severe DEXA range, so this is reassuring.
I hope your SEs are minimal too and that you get good results. Thank you so much!! Kolika

REPLY
dianestanley | @dianestanley | Jan 14, 2023
In reply to @baguette "Thanks for sharing your experience. Glad it worked out that you didn't have to pay anything..." + (show)
@baguette

Thanks for sharing your experience. Glad it worked out that you didn't have to pay anything after the leap of faith agreeing to the drug without knowing cost.

I do not have a broken bone yet so sounds like I can't get Evenity anyway. I preferred a monthly injection instead of a daily that I did myself. I don't understand the logic of waiting until someone who has been DX'd with severe osteoporosis breaks a bone before gaining access to a drug known to help greatly in addressing the disease.

Good luck with your treatment. That's great that you can feel the drug making you stronger.

Jump to this post

I would check with Amegen about having to have a prior break. You may only have to be in a certain range.

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