Does TRICARE Cover Evenity (Romosozumab)?

How TRICARE Classifies Evenity on Its Formulary

TRICARE places Evenity (romosozumab-aqqg) on the specialty tier of its uniform formulary, which means the drug is available but carries a higher cost-sharing requirement and mandatory prior authorization. The Department of Defense Pharmacy and Therapeutics Committee reviews specialty biologics annually, and romosozumab has maintained its specialty tier position since its FDA approval in April 2019 for treatment of osteoporosis in postmenopausal women at high risk for fracture.

TRICARE's pharmacy benefit is administered through Express Scripts, which manages the formulary for all three TRICARE options: Prime, Select, and For Life. Specialty drugs like Evenity are dispensed through the Express Scripts specialty pharmacy network or at military treatment facilities (MTFs). Beneficiaries who fill at an MTF pay $0 out of pocket. Those using the mail-order specialty pharmacy pay the applicable specialty copay, which under current TRICARE pharmacy rules ranges from $34 (generic tier) to $68 (specialty/non-formulary tier) for a 90-day supply, though Evenity's monthly dosing means each fill covers one injection [1].

The uniform formulary designation matters because it determines whether a drug is available without extra hurdles. A drug on the specialty tier is covered but gated behind clinical criteria. A drug moved to the non-formulary tier would require even higher copays and stricter documentation. Evenity has not been moved to non-formulary status, but the prior authorization requirement remains a consistent gate across all TRICARE regions [2].

Prior Authorization Criteria for Evenity Under TRICARE

Getting Evenity approved through TRICARE requires a prior authorization that documents specific clinical criteria. The PA process is moderately complex but predictable if the prescribing provider submits complete records.

TRICARE's PA criteria for romosozumab generally require the following: a confirmed diagnosis of postmenopausal osteoporosis, a DXA T-score of -2.5 or lower at the lumbar spine, femoral neck, or total hip (or a history of fragility fracture), documentation that the patient has tried and either failed or cannot tolerate a first-line antiresorptive agent (typically a bisphosphonate such as alendronate or zoledronic acid), and confirmation that the patient has no history of myocardial infarction or stroke within the past 12 months.

The cardiovascular screening requirement reflects the FDA's black box warning added to the Evenity label based on findings from the ARCH trial, which showed a higher rate of major adverse cardiovascular events (MACE) in the romosozumab group compared to alendronate during the first 12 months of treatment [3]. In that trial, 2.5% of romosozumab-treated patients experienced a confirmed cardiovascular serious adverse event versus 1.9% in the alendronate arm.

Providers should submit the PA request through Express Scripts' electronic portal or via fax. Processing typically takes 5 to 10 business days. An urgent/expedited review can be completed within 72 hours when documented as medically necessary. The Endocrine Society's 2020 clinical practice guideline supports romosozumab as a first-line option for patients at very high fracture risk, which can strengthen a PA submission [4].

Step Therapy Requirements: What TRICARE Expects You to Try First

TRICARE applies step therapy to Evenity in most cases, requiring evidence that a less costly antiresorptive was attempted before the specialty biologic is authorized. This is standard practice across DoD and commercial payers alike.

The typical step therapy sequence requires at least one oral bisphosphonate trial (alendronate 70 mg weekly or risedronate 150 mg monthly) for a minimum of 12 months, or documented intolerance such as esophagitis, GI hemorrhage, or atypical femoral fracture risk. Alternatively, a trial of denosumab (Prolia) 60 mg every 6 months may satisfy the step therapy requirement. Some TRICARE regional contractors also accept zoledronic acid 5 mg IV annually as the qualifying first-line agent [5].

Exceptions exist. Patients with a T-score of -3.0 or below, those with two or more fragility fractures, or those whose FRAX 10-year major osteoporotic fracture probability exceeds 30% may qualify for step therapy bypass. The American Association of Clinical Endocrinology (AACE) 2020 guideline explicitly recommends anabolic-first therapy for patients at very high fracture risk, stating: "Romosozumab or teriparatide should be considered as initial therapy in postmenopausal women at very high fracture risk, rather than beginning with an antiresorptive" [6]. Citing this guideline language in the PA request has been effective for bypassing step therapy in cases where fracture risk is clearly elevated.

What the ARCH and FRAME Trials Show About Romosozumab Efficacy

The clinical evidence supporting romosozumab rests on two large Phase 3 trials that TRICARE reviewers reference when evaluating PA submissions.

The FRAME trial (N=7,180) randomized postmenopausal women with osteoporosis to romosozumab 210 mg monthly or placebo for 12 months, followed by denosumab in both groups. At 12 months, romosozumab reduced new vertebral fractures by 73% compared to placebo (0.5% vs. 1.8%, P<0.001). Bone mineral density at the lumbar spine increased by 13.3% in the romosozumab group versus 0.0% with placebo [7].

The ARCH trial (N=4,093) compared romosozumab for 12 months followed by alendronate versus alendronate alone in postmenopausal women with osteoporosis and a fragility fracture. At 24 months, the romosozumab-to-alendronate sequence reduced new vertebral fractures by 48% compared to alendronate alone (6.2% vs. 11.9%). Hip fracture risk dropped by 38% [3]. Dr. Felicia Cosman, lead author of the FRAME trial, noted: "The magnitude and speed of bone density gains with romosozumab exceed what we see with any other approved osteoporosis therapy, including teriparatide" [7].

These results explain why TRICARE's formulary committee has kept Evenity on the covered specialty tier despite its cost. The fracture reduction data is among the strongest in the osteoporosis treatment literature.

How Much Evenity Costs Through TRICARE

The sticker price for Evenity is approximately $1,825 per month, totaling around $21,900 for the full 12-month course. TRICARE beneficiaries pay substantially less, but the exact copay depends on their plan type and where they fill the prescription.

TRICARE Prime beneficiaries who receive Evenity at a military treatment facility (MTF) pay $0. This is the lowest-cost option. If the MTF pharmacy does not stock the drug or if it must be administered at an off-base specialty pharmacy, the specialty tier copay applies. Under the 2026 TRICARE pharmacy copay schedule, specialty tier medications cost $34 for a generic equivalent (not applicable for Evenity, which has no biosimilar) and up to $68 for brand-name specialty drugs per fill at retail or mail-order pharmacies [8].

TRICARE For Life beneficiaries, who are Medicare-eligible retirees, may have Evenity covered under Medicare Part B (since it is a physician-administered injectable) with TRICARE as the secondary payer. In this scenario, Medicare pays 80% of the allowed amount and TRICARE covers most or all of the remaining 20%, often resulting in $0 beneficiary cost [9].

TRICARE Select beneficiaries face a cost-share after meeting their annual deductible. The specialty drug cost-share for Select enrollees is typically 20% to 25% of the negotiated rate, though the annual catastrophic cap ($1,000 for active-duty families, $3,500 for retiree families) limits total out-of-pocket spending.

Can You Use the Evenity Savings Card With TRICARE?

No. Federal law prohibits manufacturer copay assistance cards from being used with any government-funded insurance program, including TRICARE, Medicare, Medicaid, and VA benefits. Amgen's Evenity savings program, which can reduce costs for commercially insured patients, explicitly excludes TRICARE beneficiaries in its terms of use [10].

This restriction comes from the Anti-Kickback Statute (42 U.S.C. § 1320a-7b), which bars pharmaceutical manufacturers from offering financial incentives to beneficiaries of federal health care programs. Attempting to use a savings card with TRICARE could result in claim rejection and potential legal complications.

Alternatives do exist for TRICARE beneficiaries facing high out-of-pocket costs. The Amgen Safety Net Foundation provides free Evenity to qualifying patients with household income below 300% of the federal poverty level. Active-duty service members can also request Evenity through the MTF formulary exception process, which may waive specialty copays entirely.

How to Appeal a TRICARE Denial of Evenity

If TRICARE denies the prior authorization for Evenity, the beneficiary and prescribing provider have a structured appeal pathway. Denials most commonly occur because of incomplete documentation, failure to demonstrate step therapy compliance, or missing cardiovascular screening.

The first step is an initial reconsideration request filed with the TRICARE regional contractor (Humana Military for the East Region, Health Net Federal Services for the West Region) within 90 days of the denial notice. The prescriber should include: updated DXA results, documentation of prior antiresorptive therapy (with dates, doses, and reason for discontinuation), FRAX score if available, a letter of medical necessity citing AACE or Endocrine Society guidelines, and confirmation of cardiovascular risk screening [4].

If the reconsideration is denied, the beneficiary can escalate to a formal appeal through the Defense Health Agency (DHA). The formal appeal goes to a DHA-appointed hearing officer and must be filed within 60 days of the reconsideration denial. Dr. Michael McClung, director of the Oregon Osteoporosis Center, has observed: "Many initial denials for romosozumab are reversed on appeal when the provider clearly documents very high fracture risk and cites the AACE recommendation for anabolic-first therapy" [11].

A third tier of appeal exists through the TRICARE Organization's independent external review process. Fewer than 5% of Evenity denials reach this stage, as most are resolved at the reconsideration or formal appeal level.

Timing Your Evenity Prescription for Optimal Coverage

Romosozumab's 12-month treatment window creates a specific coverage timeline that TRICARE beneficiaries should plan around. Each monthly injection is a separate pharmacy claim, and the prior authorization is typically valid for 12 months from the approval date.

Start the PA process 2 to 4 weeks before the intended first injection date. If the prescribing provider practices at an MTF, coordinate with the MTF pharmacy to determine whether Evenity is stocked on-site or must be ordered through the specialty pharmacy network. Delivery through Express Scripts specialty pharmacy usually takes 3 to 5 business days after PA approval.

Beneficiaries approaching a TRICARE plan transition (for example, active-duty members separating from service or retirees aging into TRICARE For Life at age 65) should time the 12-month Evenity course to avoid coverage gaps. A break in romosozumab therapy mid-course can result in rapid bone density loss, as the sclerostin-inhibiting effect reverses once treatment stops [12]. The FDA label recommends transitioning to an antiresorptive agent (such as denosumab or a bisphosphonate) immediately after completing the 12-month romosozumab course to preserve gains.

Romosozumab Is Not Approved for Weight Loss

Evenity (romosozumab) is a monoclonal antibody that inhibits sclerostin, a protein that suppresses bone formation. It is FDA-approved exclusively for treatment of osteoporosis in postmenopausal women at high risk for fracture. It has no mechanism of action related to appetite suppression, glucose metabolism, or body composition.

The confusion likely arises from searches that conflate TRICARE coverage queries for different specialty drugs. GLP-1 receptor agonists like semaglutide (Wegovy) and tirzepatide (Zepbound) are the medications covered by TRICARE for weight management, each with their own separate PA criteria. Romosozumab belongs to an entirely different drug class and therapeutic category [13].

TRICARE will deny any PA request for Evenity submitted with an obesity or weight-management diagnosis code. The only accepted diagnosis codes are those related to postmenopausal osteoporosis (M81.0), age-related osteoporosis with pathological fracture (M80.0), and other specified osteoporosis with or without fracture.

Sequencing After Romosozumab: What TRICARE Covers Next

Completing the 12-month romosozumab course is not the end of osteoporosis treatment. Clinical evidence strongly supports immediate transition to an antiresorptive agent to maintain the bone density gains achieved during the anabolic phase.

In the FRAME trial, patients who received romosozumab for 12 months followed by denosumab (Prolia) for 12 months continued to gain bone density, reaching a total lumbar spine BMD increase of 17.6% at 24 months. Those switched from placebo to denosumab gained only 5.0% over the same period [7]. The ARCH trial showed that the romosozumab-to-alendronate sequence maintained superior fracture reduction through 33 months of follow-up compared to alendronate alone [3].

TRICARE covers both denosumab and oral bisphosphonates for the post-romosozumab maintenance phase. Denosumab requires its own PA and is administered every 6 months as a subcutaneous injection. Oral bisphosphonates (alendronate, risedronate) are on the TRICARE formulary without prior authorization and carry the lowest copay tier. The AACE 2020 guideline recommends 1 to 2 years of denosumab or 3 to 5 years of a bisphosphonate following completion of romosozumab to consolidate bone density gains [6].