Medicare's Coverage of Evenity
Medicare Part B covers Evenity (abaloparatide), a medication for osteoporosis, but only under specific conditions. The drug is covered when prescribed by your doctor for postmenopausal women with osteoporosis who are at high risk of breaking a bone. You will pay 20% of the cost after you meet your Part B deductible, and the medication must be given as an injection in your doctor's office or an outpatient clinic — not at home.
Evenity is not automatically covered for everyone with osteoporosis. Your doctor will need to document that you meet Medicare's criteria, which typically means you have a bone density test showing osteoporosis and either a previous fracture or other risk factors that make fracture likely. If your doctor prescribes it and Medicare denies coverage, you have the right to appeal the decision.
Key Takeaways
- Medicare Part B covers Evenity injections when your doctor prescribes them for postmenopausal women with osteoporosis at high risk of fracture.
- You pay 20% of the cost after meeting your Part B deductible; the exact amount depends on what your doctor's office or clinic charges.
- The injection must be given in a medical setting, not self-administered at home, which affects where you can receive treatment.
- Your doctor must document that you meet Medicare's medical necessity criteria before the claim will be covered.
- If Medicare denies coverage, you can request an appeal and ask your doctor to provide additional medical information supporting the need for this drug.
How Medicare Determines Coverage for Evenity
Medicare uses a process called "medical necessity review" to decide whether to cover Evenity for you. Your doctor submits information about your bone density, your age, your fracture history, and any other risk factors. Medicare's contractor in your state reviews this information against national coverage rules and local coverage decisions (LCDs) that may explore in your area.
The rules are not the same everywhere. Some states have stricter LCDs than others, which means coverage decisions can vary by location. Your doctor's office should know whether Evenity is typically covered in your area, but the only way to know for certain is to submit the claim or ask for a coverage information before treatment begins.
What You Will Pay Out of Pocket
Your costs depend on three things: whether you have met your Part B deductible for the year, what your doctor's office charges for the injection, and whether your supplemental insurance or state Medicaid program covers any of the remaining cost.
If you have not met your Part B deductible (which is $226 in 2024, though this amount changes yearly), you pay the full cost of the injection until you reach that amount. After you meet the deductible, you pay 20% of what Medicare approves as the reasonable charge. If your doctor's office charges more than Medicare's approved amount, you may owe the difference as well — this is called "balance billing," and it is legal in most cases.
If you have a Medigap (supplemental) policy, it may cover some or all of your 20% coinsurance. If you have Medicaid in addition to Medicare, Medicaid may cover costs that Medicare does not. Call your supplemental insurance company or your state Medicaid office to ask what they cover for Evenity.
Where You Can Receive Evenity Injections
Evenity must be injected by a healthcare provider in a medical setting. You cannot inject it yourself at home, unlike some other osteoporosis medications. This means you will receive the injection at your doctor's office, an outpatient clinic, or a hospital outpatient department.
The medication is given as a once-monthly injection for 12 months. After 12 months of treatment, your doctor will decide whether to continue with a different osteoporosis medication or stop treatment. Ask your doctor which location is most convenient for you and whether they can schedule all 12 injections in advance so you do not have to call each month.
What to Do If Medicare Denies Coverage
If your claim is denied, you will receive a notice called an "Explanation of Benefits" (EOB) that explains the reason. Common reasons for denial include: your bone density test does not show osteoporosis, you do not have a fracture or other documented risk factor, or your state's local coverage decision does not cover Evenity for your situation.
You have the right to appeal. Ask your doctor to write a letter explaining why Evenity is medically necessary for you — for example, if you have had a previous fracture, cannot tolerate other osteoporosis drugs, or have other conditions that make fracture very likely. Your doctor can submit this letter along with your appeal. The appeal process takes time, usually 30 to 60 days, so contact Medicare or your doctor's office right away if you want to pursue it.
Evenity Versus Other Osteoporosis Medications Medicare Covers
Medicare covers several osteoporosis medications, and they work in different ways. Evenity (abaloparatide) is an anabolic agent, meaning it helps your body build new bone. Other medications like alendronate (Fosamax) and risedronate (Actonel) slow bone loss instead. Denosumab (Prolia) is another option that slows bone loss and is given as an injection twice a year.
The choice between these medications depends on your bone density, your fracture history, how well you tolerate each drug, and whether you can take it as prescribed. Alendronate and risedronate are pills taken weekly or monthly, which some people find easier than monthly injections. Denosumab is also an injection but is given less often. Talk with your doctor about which medication is the best fit for your situation and which one Medicare is most likely to cover for you.
Questions to Ask Your Doctor
Before your doctor prescribes Evenity, ask these questions to understand your coverage and treatment plan:
- Do you think Evenity is the right medication for my osteoporosis, or should I try another drug first?
- Will you submit a coverage information request to Medicare before I start treatment, so we know in advance whether it will be covered?
- If Medicare denies coverage, will you appeal and provide additional medical information to support the need for this drug?
- How much will I pay out of pocket for each injection, and do you know whether my supplemental insurance covers any of the cost?
- Where will I receive the injections, and can you schedule all 12 months in advance?
- What should I do if I have side effects or cannot tolerate the medication?
Frequently Asked Questions
Does Medicare Part D cover Evenity?
No. Evenity is covered under Medicare Part B because it is administered by a healthcare provider in a medical setting, not self-injected at home. Part D covers oral medications and some self-injected drugs, but Evenity does not fall into either category.
Can I get Evenity if I have Original Medicare and a Medigap policy?
Yes. Your Medigap policy may cover some or all of your 20% coinsurance after Medicare pays its share. Call your Medigap insurance company and tell them you are considering Evenity treatment so they can tell you exactly what they will cover.
What happens after 12 months of Evenity treatment?
Your doctor will reassess your bone density and decide what to do next. Some patients switch to a different osteoporosis medication to maintain bone strength. Others stop treatment if their bone density has improved enough. Your doctor will discuss the options with you based on your individual situation.
Will I have to pay for the office visit where I get the injection?
Yes, separately from the medication cost. You will owe a copay or coinsurance for the office visit itself, depending on your plan. The 20% coinsurance for the Evenity injection is separate from any charges for the visit. Ask your doctor's office what the total cost will be for each appointment.
What if my doctor's office charges more than Medicare allows?
If your doctor is enrolled in Medicare, they have agreed to accept Medicare's approved amount and cannot bill you for the difference. If your doctor is not enrolled in Medicare, they can charge you more, and you would owe the extra amount. Ask your doctor's office whether they are a Medicare-enrolled provider before starting treatment.