Evenity Medicare Coverage: What You Need to Know

Hey there! If you’re reading this, you’re probably wondering whether Medicare will foot the bill for Evenity, the once‑a‑month injection that’s been a game‑changer for many women with postmenopausal osteoporosis. The short answer? Yes—if you meet the right medical criteria and your doctor and the clinic are Medicare‑ready. In the next few minutes we’ll walk through exactly how that works, what it’ll cost you, and the steps you can take right now to make the process as smooth as possible.

Think of this guide as a friendly coffee‑chat with a knowledgeable buddy who’s done a deep dive into the policies, talked to specialists, and even heard a few patient stories along the way. Grab a cup, get comfortable, and let’s unpack Evenity Medicare coverage together.

How Medicare Parts Apply

Medicare Part B – the default payer for office‑administered injections

Evenity is a subcutaneous injection that must be given by a healthcare professional in a clinic or infusion center. Because it’s not a self‑administered pill, the cost falls under Medicare Part B, which covers services provided in a doctor’s office. The claim is usually billed with HCPCS code J3111 (injection, romosozumab‑aqgg, 1 mg). Once the yearly Part B deductible (currently $257) is met, Medicare typically picks up 80 % of the allowed amount, leaving you with a 20 % coinsurance.

When Part A can step in

If you happen to receive Evenity while you’re admitted to a hospital—say, after a hip fracture—Part A may cover the drug during that inpatient stay. Part A’s first‑60‑day benefit has a separate deductible ($1,676 in 2025) and then generally pays the full allowed amount for covered services.

Medicare Advantage (Part C) and private plans

Medicare Advantage (MA) plans are required to offer at least the same benefits as Original Medicare (Parts A and B). Most MA plans cover Evenity under the same Part B rules, but they can add their own cost‑sharing structures, preferred specialty pharmacies, or prior‑authorization portals. It’s a good idea to call your MA plan’s member services line and ask, “Do you cover Evenity injection, and what’s the coinsurance after the Part B deductible?”

Why Part D does NOT cover Evenity

Part D is the prescription‑drug benefit that handles pills you can take at home. Because Evenity must be administered by a professional, it falls outside the scope of Part D. This distinction is clearly explained in a Healthline article that outlines why injectable biologics belong to Part B instead.

Eligibility Criteria Explained

Clinical indication: post‑menopausal osteoporosis at high fracture risk

Medicare will only consider Evenity medically necessary if you’re a post‑menopausal woman who is at high risk for a fracture. The typical markers include:

• DXA (bone density) T‑score ≤ ‑2.5 at the lumbar spine, femoral neck, total hip, or forearm.
• Or a T‑score between ‑1.0 and ‑2.5 combined with a FRAX 10‑year probability ≥ 20 % for a major osteoporotic fracture or ≥ 3 % for a hip fracture.
• Or a history of a fragility fracture (hip, vertebral, proximal humerus, pelvis, or distal forearm) regardless of T‑score.

Prior‑therapy requirements

Before you can start Evenity, you must have tried— and either failed or been unable to take— another osteoporosis therapy:

• At least 12 months of oral or IV bisphosphonate (e.g., alendronate, risedronate, ibandronate, zoledronic acid), or
• Intolerance or contraindication to both oral and IV bisphosphonates, or
• Failure of a RANKL inhibitor such as denosumab (Prolia).

Safety exclusions

Evenity is not covered if you’ve had a myocardial infarction or stroke within the past 12 months, or if you have active hypocalcemia. These safety windows protect patients from the medication’s rare cardiovascular warnings noted in the FDA label.

Policy snapshots (real‑world sources)

Several payer policies spell out the same criteria:

• Blue Cross Blue Shield (Louisiana) Medicare Advantage Policy #102 – lists T‑score thresholds, FRAX scores, and prior‑therapy failures.
• Highmark Medical Policy I‑216‑007 – mirrors the same eligibility and safety exclusions.
• OHSU’s internal guideline (PDF) repeats the dosage limit of 12 injections over a lifetime and the requirement for no concurrent osteoporosis agents.

How clinicians document

When your doctor submits the prior‑authorization, they’ll typically attach:

• Recent DXA report showing T‑score.
• FRAX calculation screenshot (or printed report).
• Medication history confirming at least 12 months of bisphosphonate or documented intolerance.
• Negative cardiac history (no MI/stroke in past year).

Cost Breakdown Overview

Understanding the dollar signs can feel overwhelming, so let’s break it down with some real numbers. All figures reflect 2025 rates and may vary by plan.

Item	Typical Amount (2025)	Who Pays?
List price of Evenity (per month)	$2,628.92	Pharmacy/manufacturer (before insurance)
Part B deductible (annual)	$257	Beneficiary (you)
Medicare Part B coverage (80 % after deductible)	≈ $2,103	Medicare
Beneficiary coinsurance (20 %)	≈ $526	You (or supplemental plan)
Standard Part B premium (starts at)	$185/month	You (income‑based)

If you have a Medigap (Supplement) plan—say, Plan F or G—your 20 % coinsurance can disappear altogether, bringing the out‑of‑pocket cost for the injection close to $0. A quick phone call to your supplemental insurer can confirm this.

Manufacturer assistance (Amgen SupportPlus)

Amgen offers a SupportPlus program that can lower the patient’s cost dramatically, but you can’t combine it with Medicare payments. This is a good option if you’re uninsured or have high coinsurance and don’t have supplemental coverage. More details are available on the Amgen website.

Real‑world out‑of‑pocket snapshots

Evenity’s own patient‑support page reports that many beneficiaries with supplemental coverage pay $0–$150 per month after insurance. These anecdotes line up with the numbers above and illustrate how the right plan can make a huge difference.

Getting Evenity Approved

1. Verify provider participation

First, make sure the clinic or infusion center you’ll visit is enrolled in Medicare and bills under the correct HCPCS code (J3111). You can use the Medicare “Provider Participation” tool on the CMS website, or simply ask the office staff: “Do you accept Medicare Part B for Evenity injections?”

2. Gather required clinical documentation

Ask your doctor for a packet that includes:

• Latest DXA scan (PDF with T‑score).
• FRAX risk calculator print‑out (or a screenshot).
• Medication history showing a failed bisphosphonate trial or documented intolerance.
• Statement confirming no MI or stroke in the past 12 months.

3. Complete the prior‑authorization form

Most carriers use a standard form that asks for diagnosis codes (usually M80.* for age‑related osteoporosis) and the procedure code J3111. Attach the documents from step 2, and double‑check that the prescriber’s NPI and the site’s Medicare billing number are correct.

4. Submit to the payer

Uploading can be done through the payer’s portal (e.g., Blue Cross’s “Blue Advantage” portal) or via fax/email if you’re dealing with a smaller regional plan. Keep a copy of the submission receipt; it’s your safety net if anything gets lost.

5. Follow‑up & appeal if denied

Denials often hinge on missing information—like forgetting to include the FRAX score. If you get a denial, request the specific reason in writing, then resubmit the missing piece. A short, polite appeal letter that restates the medical necessity and cites the same payer policy (e.g., Blue Cross #102) can overturn many initial rejections.

Real‑World Patient Stories

Maria’s journey: from fractures to freedom

Maria, 68, had a vertebral fracture in 2022 and multiple low‑impact wrist breaks. Her DXA showed a T‑score of ‑2.8, and she’d already spent a year on alendronate with no improvement. After her endocrinologist ordered Evenity, the clinic confirmed Medicare Part B coverage. With a Medigap Plan F, Maria’s coinsurance fell to $0, and after 12 months of injections her follow‑up DXA showed a 6 % increase in bone density—a result she describes as “getting my life back.”

Clinician perspective

Dr. Patel, a board‑certified rheumatologist, notes, “Evenity is a powerful tool, but we must respect the cardiovascular safety signal. I always double‑check the patient’s cardiac history and ensure the FRAX score truly reflects high risk before submitting a claim.” He adds that the most common barrier is paperwork—once the clinic’s billing staff get the hang of the prior‑authorization template, the process usually clears within 10‑14 days.

Safety data snapshot

In clinical trials, serious cardiovascular events occurred in about 0.8 % of participants receiving Evenity, compared with 0.6 % on placebo—a modest difference that underscores the importance of the “no recent heart attack or stroke” rule (FDA label).

Comparing other osteoporosis options

Medication	Route	Typical Coverage	Annual Out‑of‑Pocket (approx.)	Key Advantage
Evenity (romosozumab‑aqgg)	Monthly subcutaneous injection (clinic)	Part B (or Part C equivalent)	$0–$600 (depending on supplemental)	Dual action: builds bone & reduces resorption
Prolia (denosumab)	Quarterly injection (often pharmacy)	Part D (95 % of plans)	$40–$150 per 6 months	Convenient quarterly dosing
Generic alendronate	Weekly oral tablet	Part D	$0–$30 per month	Low cost, widely available

Evenity isn’t the cheapest choice, but for patients at very high fracture risk who need a stronger bone‑building effect, the clinical benefit often outweighs the cost—especially when insurance cushions the price.

Putting It All Together

Let’s recap the essential steps so you can feel confident moving forward:

1. Confirm your doctor’s office and the infusion center accept Medicare Part B.
2. Gather DXA results, FRAX score, and proof of prior‑therapy failure.
3. Complete the prior‑authorization form with diagnosis code M80.* and procedure code J3111.
4. Submit to your payer and keep the receipt.
5. If denied, politely appeal with the missing information or a reference to the payer’s policy (e.g., Blue Cross #102).
6. Check your supplemental coverage or manufacturer assistance to reduce the 20 % coinsurance.

Remember, you’re not alone in this. The Medicare system can feel like a maze, but the right preparation turns it into a clear‑cut path. If you stumble, reach out to a Medicare‑savvy billing specialist—many hospitals have a patient‑financial‑services team that can help.

Next Steps & How to Stay Informed

If any of this feels overwhelming, here are a few friendly actions you can take right now:

• Call your doctor’s office and ask, “Do you bill Evenity under Medicare Part B, and can you walk me through the prior‑authorization checklist?”
• Log into your Medicare portal and verify your Part B deductible status for the year.
• Contact your Medigap insurer and ask, “What will my coinsurance be for a Part B‑covered injection?”
• Consider a quick chat with Amgen SupportPlus if you lack supplemental coverage.

And hey—if you’ve already navigated this process, share your experience in the comments! Your story could be the exact piece of guidance another reader needs to feel empowered.

We’ve covered the medical criteria, the insurance mechanics, the cost realities, and even a couple of personal stories. I hope this feels less like a dry policy read and more like a helpful conversation with a friend who’s got your back.

Take care of your bones, stay proactive, and remember: Medicare is there to help you get the treatment you need—once you know the right questions to ask.