Problems with getting Evenity insurance coverage
I was trying so hard to make sure that I didn't start Evenity until I knew that I had insurance coverage for it. Last month, I had to report that I had one less dependent (due to my son finding a job) and got kicked out of my ACA Marketplace Insurance. The UHC insurance that became available to me (after I updated my income and dependent information in ACA Marketplace) did not have Evenity in the formulary and Evenity was not eligible for pre-authorization.
Update: I talked to two UHC reps who said that my new insurance plan doesn't have Evenity in the formulary and that there is no PA for Evenity on my plan. The infusion center called up UHC and talked to a rep who said that my new insurance plan currently shows that there is a PA for Evenity. I guess that I will go for the infusion appointment and will later find out which UHC rep was correct (when my claim is processed).
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My insurance stated the clinic charged $7,856.00 per month. Luckily my insurance is cover in it.
Evenity might not be in the formulary because it's considered a medical treatment that must be delivered in the doctor's office or an infusion center, not a prescription medication that is processed through a third-part pharmacy provider. Your doctor should submit the request and go from there.
It was easier for mine to get the treatment approved because of that. I had a runaround with both Tymlos and teraparatide because they went through the approval process for a prescription drug.
It's important that you see a specialist who best understands how to submit the request to the insurance company.
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