evenity Bone injection
- Thread starter vic120
- Start date
Jim Wright
Super Genius
- 230
Usually if the provider/facility is in network, any procedure/drug they perform will be covered as long as the prior auth, etc is followed by the provider
- Thread starter
- #3
OK because he is asking for his wife due to the fact that his current BC plan from employer is not covering
Its a bone injection she needs because of cancer treatments
Is ACA dif than employer group?
Jim Wright
Super Genius
- 230
Hard to say. Depends on if the plan is fully insured/self funded/etc. Those plans get pretty specific on what they cover and won't. It would still be worth an email to the ACA carrier rep or have your rep from your FMO find the answer for you.
Jim is correct about the group plan issue, but I would want to know more about this situation. Your initial question causes me to pause, I have seen too many of these situations over the years where a question is asked, with very little background information.
Evenity Bone injection is a treatment for osteoporosis in postmenopausal women to help reduce the risk of bone fractures. As with all drugs/treatments there are side effects, complications and other issues. Putting aside the issue of whether the injections are a covered expense or not, is there a chance there is a medical reason for not using it now? I would want to know more about this first.
My background is in group benefits, not medical. I am not looking to cast aspersions at your friend but there could be other reasons, grounded in medical concerns, that the plan is not covering the medication.
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- #6
Not really sure I understand your question
But the back ground is she has cancer and has been under a lot of treatments that has caused weaking in the bones
the doctored ordered this medication to be administered from the doctor, but the insurance has said they will not cover it
I just spoke to the ex husband and he is telling me second hand and this is all I have
Sorry for confusion. At this point in time, I see 2 possible reasons why the carrier is refusing the use of the drug. The 1rst is that the plan does not recognize it as an eligible expense, as Jim mentioned in his reply. The 2nd is that the plan does allow for it but based on the medical condition they are not approving its use.
My concern is about how the question is being asked (How does ACA plans cover these types of drugs that are doctor administered?) with minimal background information. I could review the plan documents and find the drug is indeed a covered expense, only to find out that the issue is medical necessity, not plan expense eligibility. Can't tell you how many times people have come to this site, asked a question with minimal background information, and then later on we find out more which causes the original answers to be incorrect.
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- #8
I get it
However I understand more
It seems that it might be an issue with any carrier if it is not coded right
or it could be the type of plan she has now
My guess is medical necessity.
The class of medication is covered, but you need more information.
Because I'm at 99% that if Evenity isn't covered, then Prolia would be covered.
However, if they are doing it for preventative reasons vs an osteoporosis diagnosis, you've got a problem. Its not approved by the FDA for preventative. No one is going to cover it.
Go back to client and have them call the doctors office. Ask about Prolia and see if they can change the billing codes to get it covered.
Because I'm at 99% that if Evenity isn't covered, then Prolia would be covered.
However, if they are doing it for preventative reasons vs an osteoporosis diagnosis, you've got a problem. Its not approved by the FDA for preventative. No one is going to cover it.
Go back to client and have them call the doctors office. Ask about Prolia and see if they can change the billing codes to get it covered.
