Evenity denied as non-formulary by Aetna?

Aetna's specific coverage criteria for evenity are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Aetna Denied Evenity as Non-Formulary

Evenity (romosozumab) is a specialty biologic agent. Aetna places it on a high specialty tier or excludes it from some formularies entirely, which triggers a non-formulary denial when the prescription is submitted without a prior formulary exception request. This is distinct from a medical-necessity denial — the plan is not saying the drug is clinically inappropriate; it is saying it is not on the preferred drug list for your specific plan benefit design. The formulary tier and exception process vary by plan year and employer contract, so you should request your plan's current formulary document and the formulary exception criteria.

## Why This Denial Is Appealable

Federal and state law require that plans maintain a formulary exception process. If no clinically equivalent formulary alternative exists, or if formulary alternatives are contraindicated or have caused documented adverse effects, you are entitled to a formulary exception. You are also entitled to a full internal appeal under ERISA §503 or your state's insurance law, and to independent external review under ACA §2719 after internal remedies are exhausted, generally within approximately four months of the final internal denial.

## Your Appeal Timeline

1. Confirm with Aetna which formulary alternatives (if any) they consider therapeutically equivalent for your diagnosis. 2. Request the formulary exception form — this is a distinct process from a standard grievance in most Aetna plans. 3. File the exception request with supporting documentation. 4. If the exception is denied, file a formal internal appeal and then escalate to external review.

## Documentation to Gather

• Diagnosis confirmation: DXA scan reports, fracture history, and clinical notes establishing severe osteoporosis and high fracture risk.
• Formulary alternative failure or contraindication: For each alternative Aetna identifies as equivalent, provide documented evidence that it was tried and failed, is medically contraindicated for this patient, or would be clinically inferior — with specific reference to chart notes and pharmacy records.
• Prescriber medical-necessity letter for formulary exception: A letter from your prescribing physician addressing the specific formulary alternatives Aetna lists, explaining why each is not appropriate for this patient, and stating that Evenity is the clinically necessary choice.
• Prior treatment history: Pharmacy records and office notes documenting the timeline of osteoporosis treatment and why available formulary alternatives are insufficient.

## Criteria-Mapping Structure

Obtain Aetna's formulary exception criteria for specialty drugs. Then map each criterion:

| Exception Criterion | Your Documentation | |---|---| | No therapeutically equivalent formulary alternative | Cite each alternative and why it is unsuitable | | Medical contraindication to alternatives | Cite chart notes or allergy/adverse-effect records | | Clinical necessity of requested drug | Cite prescriber letter and diagnosis documentation |

Identifying and addressing every formulary alternative Aetna lists — and providing a specific clinical reason why each one is unsuitable — is the central task in a non-formulary exception appeal for Evenity.