1. < Osteoporosis & Bone Health

Stopping Evenity

Posted by susanew @susanew, 1 day ago

I have had 7 treatments but now have decided to stop due to the fact my doctor’s office now insists all Medicare HMO advantage patients use the pharmacy portion of insurance. What this means is that I buy drug and pay out of pocket and have it sent to doctor’s office. Before, they provided drug and billed insurance under medical portion and I paid remainder. Doing it the new way will double my cost because I will no longer be able to apply payments to out of pocket expense when using drug portion of insurance.

My question is, what can I use now instead of Evenity. Reclast?

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Mentor
Sue, Volunteer Mentor | @sueinmn | 5 hours ago
In reply to @rjd "I did not ask anything about preferred providers but your explanation is not my understanding of..." + (show)
@rjd

I did not ask anything about preferred providers but your explanation is not my understanding of PPO. So if you would share the source of your information, I would appreciate it.

My understanding of the consumer /patient benefit of a PPO is that referrals are not needed to see doctors who are otherwise in the insurers network. This is in contrast to an Advantage 'HMO' where the PCP must refer you to others for any services.

How PPO works in practice can be a bit of a mystery,

However, the point of my question had to do with whether it is kosher for a doctor who accepts an Advantage plan to then decide which part of an Advantage plan he prefers to use. I hope //think you are correct that that is NOT something the doctor decides. If Evenity is covered by Medicare Part B, then it does not seem the doctor can simply decide NO, you must procure the medication via Part D.

I guess this raises the question: can Evenity be procured/processed under either Part B or Part D?

The original poster seems to think there is much more out of her pocket when under Part D and that is why she is quitting treatment. I do not see how Part D, with its new $2000 cap, can be more expensive than Part B so someone needs to crunch the numbers with the original poster.

That is in part why I suggested she contact the SHIP in her state or the Medicare Rights Center....(along with the other reason about her doctor making such a decision about which Part he wants to use and the insurer saying that is OK.)

The way Medicare works in this country is an unpardonable sin....

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As for the Part B vs Part D drug cost differences, many Medicare plans have either zero or very low copay for Part B expenses, and each copay counts towards their out-of-pocket total for the year. Part D,on the other hand, carries its own copay that count towards the $2000 cap but not the out-of-pocket limit. That extra $2000 expenditure can mean the difference between being able to cover expenses or doing without to many people.

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