Medicare covers Evenity, but only under specific conditions
Evenity (abaloparatide) is a bone-building injection used to treat osteoporosis in people at high risk of fracture. Medicare Part B covers it, but you will need a prescription from your doctor, and your doctor will need to document that you meet certain medical criteria. The drug is given as a once-daily injection that you can administer yourself at home.
Coverage is not automatic. Your doctor must show that you have osteoporosis (confirmed by bone density scan) and either have had an osteoporotic fracture, or have very low bone density, or have failed to respond to other osteoporosis treatments. Medicare will also check that the dose and frequency your doctor prescribes match what the Food and Drug Administration approved.
Key Takeaways
- Medicare Part B covers Evenity injections when prescribed by your doctor for osteoporosis with documented high fracture risk.
- Your doctor must submit medical records showing your bone density scan results and fracture history before Medicare will pay.
- You will owe a 20 percent coinsurance on the cost of the drug after you meet your Part B deductible for the year.
- If your doctor's office administers the injection, you may owe an additional office visit copay or coinsurance.
- Some Medicare Advantage plans cover Evenity differently, so check your plan documents or call your plan's customer service line.
How Medicare Part B pays for Evenity
When your doctor prescribes Evenity, the prescription goes to a pharmacy or your doctor's office, depending on where you receive the injection. If you get it at a pharmacy, Medicare Part B covers the drug itself. If your doctor's office gives you the injection, Medicare covers both the drug and the administration fee for the injection.
You pay 20 percent of the Medicare-approved amount for the drug after you have met your Part B deductible (which is $240 in 2024, though this amount changes yearly). The remaining 80 percent is covered by Medicare. If your doctor's office administers it, you will also owe coinsurance on the administration charge, which is typically a smaller amount.
Evenity is a brand-name drug, so there is no generic version. The cost to Medicare is higher than some other osteoporosis treatments, which is why your doctor's documentation of medical need is important before Medicare will pay.
What your doctor needs to document for coverage
Medicare requires your doctor to show that you have osteoporosis and are at high risk of fracture. This means your doctor will need to submit:
- Results of a bone density scan (DEXA scan), showing T-score of –2.5 or lower, or
- Evidence of a previous osteoporotic fracture (hip, spine, or wrist), or
- Documentation that you have taken another osteoporosis drug for at least 12 months without adequate response
Your doctor's office typically handles this paperwork. They send it to Medicare (or to your Medicare Advantage plan) before you start the medication. If Medicare needs more information, your doctor's office will receive a request and can submit additional records. This process usually takes a few days to a couple of weeks.
Medicare Advantage plans and Evenity
If you are enrolled in a Medicare Advantage plan (Part C), your coverage for Evenity may differ from Original Medicare. Some Advantage plans cover Evenity the same way Part B does; others may require you to use a specific pharmacy, or may charge different copays or coinsurance amounts.
Check your plan's formulary (the list of covered drugs) or call your plan's customer service number, which is on your insurance card. Ask whether Evenity is on the formulary, what your out-of-pocket cost will be, and whether your doctor needs prior authorization before prescribing it. Some plans require your doctor to show that you have tried another osteoporosis drug first.
What you will pay out of pocket
Your costs depend on whether you have met your Part B deductible and which type of Medicare coverage you have. Under Original Medicare, you pay 20 percent coinsurance on the drug cost after your deductible. Evenity is typically given once a month, so your monthly coinsurance will vary based on the Medicare-approved price, which changes periodically.
If you cannot afford the coinsurance, ask your doctor's office about patient information programs run by the drug manufacturer. These programs sometimes reduce or eliminate your out-of-pocket cost if your income is below a certain level. Your doctor's office can help you find out whether you may have access to.
If you are enrolled in a Medicare Advantage plan, your costs may be lower or higher depending on your plan. Some plans have a flat copay for injectable drugs; others use coinsurance. Review your plan documents or call your plan to find out your exact cost before you start the medication.
Prior authorization and timing
Some Medicare Advantage plans require prior authorization before your doctor can prescribe Evenity. This means your doctor's office must contact the plan and get approval before the prescription is filled. Original Medicare does not require prior authorization for Evenity, but your doctor still needs to document medical necessity.
If your plan requires prior authorization, the process usually takes 1 to 3 business days. Your doctor's office handles the request, so ask them how long it typically takes in your area. If the plan denies the request, your doctor can appeal or discuss alternative osteoporosis treatments with you.
Other osteoporosis drugs Medicare covers
If Evenity is not covered by your plan, or if the cost is too high, Medicare covers other osteoporosis medications. These include bisphosphonates (such as alendronate and risedronate), which are often available as generic drugs and cost less. Denosumab (Prolia) is another option that Medicare covers. Your doctor can discuss which drug is best for your bone health and your budget.
Some of these alternatives are taken by mouth once a week or once a month, while others are injections given less frequently than Evenity. Talk with your doctor about the pros and cons of each option, including how often you need to take the medication and what your out-of-pocket cost will be.
Frequently Asked Questions
Do I need prior authorization from Medicare to get Evenity?
Original Medicare does not require prior authorization, but your doctor must document that you have osteoporosis with high fracture risk. If you have a Medicare Advantage plan, check your plan documents or call customer service to find out whether your plan requires prior authorization before your doctor prescribes it.
Will Medicare pay for Evenity if I have already tried another osteoporosis drug?
Yes. In fact, some Medicare Advantage plans require you to try another drug first. If you have taken another osteoporosis medication for at least 12 months without adequate response, that strengthens your case for coverage of Evenity. Your doctor can document this in the medical records sent to Medicare.
What if my doctor's office administers the Evenity injection instead of me doing it at home?
Medicare will cover both the drug and the administration fee. You will owe 20 percent coinsurance on the drug cost and coinsurance on the administration charge (usually a smaller amount) after you meet your Part B deductible. Ask your doctor's office what the administration fee is before your first injection.
Can I use a manufacturer coupon or patient information program to lower my Evenity cost?
Yes. The drug manufacturer offers patient information programs that may reduce your out-of-pocket cost if your income qualifies. Ask your doctor's office for information about these programs, or visit the manufacturer's website. You can use these programs alongside Medicare coverage.
What happens if Medicare denies coverage for Evenity?
Your doctor can appeal the denial by submitting additional medical records or a letter explaining why Evenity is medically necessary for you. If you have a Medicare Advantage plan and it denies coverage, you have the right to request an appeal. Your doctor's office can guide you through the appeal process.