By Counterforce Health Team in Evkeeza (evinacumab-dgnb) — 28 Oct 2025

Lowering Out-of-Pocket Costs for Evkeeza (Evinacumab) with Blue Cross Blue Shield in Ohio: Copay Programs, Appeals, and Financial Assistance

Answer Box: Getting Evkeeza Covered by Blue Cross Blue Shield in Ohio

Fastest path to approval: Have your doctor submit a prior authorization request with documented HoFH diagnosis, failed prior therapies, and current LDL-C levels. Blue Cross Blue Shield Ohio (Anthem) requires prior authorization for Evkeeza, with new clinical criteria effective December 2024. If denied, you have two internal appeals plus external review through Ohio's Department of Insurance within 180 days. Start today: Contact your prescriber to begin the PA process and enroll in Regeneron's copay assistance program (up to $25,000/year for commercial insurance).

What Drives Evkeeza Costs
Benefit Investigation: Key Questions
Copay Assistance and Financial Programs
Getting Formulary Exceptions
Specialty Pharmacy Coordination
Appeals Process in Ohio
Annual Renewal Planning
Scripts for Key Conversations

What Drives Evkeeza Costs

Evkeeza (evinacumab-dgnb) carries a wholesale acquisition cost of approximately $450,000 annually for a 75kg adult, making it one of the most expensive specialty medications. Your out-of-pocket costs depend on several benefit design factors that Blue Cross Blue Shield uses to manage high-cost therapies.

Formulary Tier Placement

Most Blue Cross plans place Evkeeza on their highest specialty tier, typically requiring 25-40% coinsurance rather than fixed copays. This means you pay a percentage of the drug's cost rather than a flat fee. For a medication this expensive, even a 25% coinsurance could mean thousands per infusion without assistance programs.

Prior Authorization Requirements

Anthem Blue Cross Blue Shield Ohio updated their clinical criteria for Evkeeza effective December 2, 2024, confirming that prior authorization is required. While specific criteria aren't publicly detailed, most major payers require:

Confirmed HoFH diagnosis (genetic testing or clinical criteria)
Documented failure or intolerance to maximum tolerated lipid-lowering therapy
Current LDL-C levels above specified thresholds (often ≥100 mg/dL on treatment)

Site of Care Restrictions

Evkeeza requires IV infusion over 60 minutes every 4 weeks, typically administered in outpatient infusion centers or specialty clinics. Some plans may restrict coverage to specific facility types or require prior authorization for the administration site.

Benefit Investigation: Key Questions

Before starting treatment, gather specific information about your Blue Cross Blue Shield coverage to understand your financial responsibility and identify potential cost-saving opportunities.

Questions for Member Services

Call the number on your insurance card and ask:

Is Evkeeza (evinacumab-dgnb) covered under my medical or pharmacy benefit?
What's my coinsurance percentage for specialty drugs?
Do I have a specialty drug deductible, and if so, how much remains?
Is there an annual out-of-pocket maximum that applies to specialty medications?
Are there preferred infusion sites or administration requirements?

Information to Record

Document the representative's name, date, and reference number for your call. Request written confirmation of coverage details, as verbal information can sometimes be incorrect or incomplete.

Tip: Ask for your plan's "Summary of Benefits and Coverage" (SBC) document, which outlines your specialty drug coverage in detail.

Copay Assistance and Financial Programs

Several programs can significantly reduce your out-of-pocket costs for Evkeeza, with manufacturer assistance being the most substantial for commercially insured patients.

Regeneron's myRARE Patient Support Program

Regeneron offers copay assistance covering up to $25,000 per calendar year for eligible patients with commercial insurance. This program typically reduces patient costs to less than $45 per treatment.

Eligibility requirements:

Commercial (private) insurance with Evkeeza coverage
Valid prescription for FDA-approved indication
US residency (excluding Rhode Island and Massachusetts for administration charges)
Not enrolled in government insurance (Medicare, Medicaid, TRICARE, VA)

To enroll: Visit myrare.com or call to speak with a Patient Navigator who can verify eligibility and guide you through enrollment.

Foundation Grants for Medicare Patients

If you have Medicare Part B, the HealthWell Foundation offers grants for hypercholesterolemia treatments including biologics like Evkeeza. The program provides an average of $1,230 annually and is available to households with income up to 500% of the federal poverty level.

To apply:

Verify the fund is open at healthwellfoundation.org/disease-funds
Gather required documentation: physician verification of HoFH diagnosis, proof of US treatment, household income details
Submit application online with supporting documents

Specialty Pharmacy Case Management

Many Blue Cross plans include case management services for high-cost medications. Contact member services to request assignment to a case manager who can:

Coordinate benefits and identify all available assistance programs
Help navigate prior authorization requirements
Facilitate communication between your care team and the insurance plan
Monitor for formulary changes that might affect coverage

Getting Formulary Exceptions

If Evkeeza isn't covered or is placed on a prohibitively expensive tier, you can request a formulary exception to improve coverage or reduce cost-sharing.

When to Request Exceptions

Consider a formulary exception request when:

Evkeeza isn't covered at all (non-formulary)
Your coinsurance creates unaffordable out-of-pocket costs
Preferred alternatives are contraindicated or have failed
Step therapy requirements don't apply to your clinical situation

Required Documentation

Your prescriber will need to submit a comprehensive medical necessity letter including:

Clinical justification:

Confirmed HoFH diagnosis with supporting genetic or clinical evidence
Complete history of prior lipid-lowering therapies and their outcomes
Current lipid levels and cardiovascular risk assessment
Explanation of why preferred alternatives are inappropriate

Supporting evidence:

Relevant clinical guidelines (American College of Cardiology, European Society of Cardiology)
FDA prescribing information for Evkeeza
Published studies demonstrating efficacy in HoFH patients

Clinician Corner: The medical necessity letter should emphasize that HoFH is a rare, life-threatening condition with limited treatment options. Reference the FDA approval specifically for HoFH and cite evidence showing Evkeeza's unique mechanism of action (ANGPTL3 inhibition) provides benefit regardless of LDL receptor function.

Specialty Pharmacy Coordination

Evkeeza's administration requirements and high cost typically require coordination with specialty pharmacies and infusion centers that have experience with complex biologics.

Choosing the Right Pharmacy

Blue Cross Blue Shield often has preferred specialty pharmacy networks that may offer:

Lower cost-sharing for specialty medications
Enhanced patient support services
Streamlined prior authorization processes
Coordination with infusion sites

Questions for your specialty pharmacy:

Do you participate in my Blue Cross Blue Shield plan's preferred network?
Can you coordinate directly with my infusion center?
What patient assistance programs do you help administer?
How do you handle insurance denials and appeals?

Infusion Site Considerations

Verify that your chosen infusion center:

Is in-network with your Blue Cross Blue Shield plan
Has experience administering Evkeeza
Can provide the required 60-minute infusion with appropriate monitoring
Accepts your specialty pharmacy's coordination

Counterforce Health helps patients navigate these complex coordination requirements by analyzing insurance policies and identifying the most efficient pathways for specialty drug approvals, including site-of-care requirements and pharmacy network considerations.

Appeals Process in Ohio

If Blue Cross Blue Shield denies coverage for Evkeeza, Ohio provides a structured appeals process with specific timelines and consumer protections.

Internal Appeals (Two Levels)

First Internal Appeal:

Deadline: 180 days from denial notice
Timeline: BCBS must respond within 30 days (72 hours for urgent)
Submit to: Address/portal specified in your denial letter

Second Internal Appeal:

Deadline: 60 days from first appeal denial
Timeline: 30 days for standard, 72 hours for urgent
Requirements: Can include new evidence or request peer-to-peer review

External Review Through Ohio Department of Insurance

After exhausting internal appeals, you can request an external review through Ohio's Department of Insurance within 180 days of your final internal denial.

Process:

Submit external review request to your insurance plan (they forward to ODI)
Independent Review Organization (IRO) assigned to your case
IRO reviews all medical records and makes binding decision
Timeline: 30 days standard, 72 hours expedited

Contact Ohio Department of Insurance:

Consumer hotline: 1-800-686-1526
External Review Request Form (verify current link)

Note: Self-funded employer plans follow federal ERISA rules rather than Ohio's external review process, but many voluntarily provide similar independent review options.

Required Documentation for Appeals

Strengthen your appeal with comprehensive evidence:

Complete medical records documenting HoFH diagnosis
Detailed history of failed therapies with specific reasons for discontinuation
Current lipid panels and cardiovascular risk assessments
Published clinical guidelines supporting Evkeeza use in HoFH
Letters from specialists (lipidologists, cardiologists) supporting medical necessity

Annual Renewal Planning

Plan ahead for potential changes that could affect your Evkeeza coverage and costs each year.

What Can Change

Formulary updates: Blue Cross Blue Shield can modify their formulary mid-year with proper notice, potentially affecting Evkeeza's tier placement or coverage status.

Benefit design changes: Annual renewals may bring changes to:

Specialty drug coinsurance percentages
Deductible amounts and structure
Out-of-pocket maximums
Preferred pharmacy networks

Assistance program renewals: Manufacturer copay programs typically reset annually and may have updated eligibility criteria or benefit amounts.

Planning Actions

Fourth quarter review: Each fall, review your upcoming year's benefits and:

Confirm Evkeeza remains covered at the same tier
Verify your infusion center and specialty pharmacy remain in-network
Re-enroll in manufacturer assistance programs
Budget for any deductible restart

Documentation maintenance: Keep current copies of:

Recent lab results and specialist notes
Letters of medical necessity
Prior authorization approvals
Assistance program enrollment confirmations

Scripts for Key Conversations

Patient Script for Blue Cross Blue Shield Member Services

"Hi, I'm calling about prior authorization for Evkeeza, also called evinacumab-dgnb. My doctor wants to prescribe this for my homozygous familial hypercholesterolemia. Can you tell me:

Is this medication covered under my plan?
What's the prior authorization process?
What's my expected out-of-pocket cost?
Are there preferred infusion sites I need to use?

My member ID is [number] and my name is [name]. Can I get a reference number for this call?"

Clinic Staff Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for [patient name] regarding coverage of Evkeeza for homozygous familial hypercholesterolemia. This patient has a confirmed genetic diagnosis and has failed maximum tolerated statin therapy plus ezetimibe. Their current LDL-C is [level] despite optimal therapy.

Could you connect me with your medical director to discuss the clinical necessity? I have the patient's complete medical records available for review."

Specialty Pharmacy Coordination Script

"I need to coordinate Evkeeza therapy for a patient with Blue Cross Blue Shield coverage. Can you confirm:

You're in-network with their plan?
Your process for handling prior authorizations?
Which infusion centers you work with in our area?
Your experience with manufacturer copay programs for this medication?

The patient will need monthly infusions, so reliable coordination is essential."

From Our Advocates

"We've seen patients initially quoted $15,000+ per infusion for Evkeeza, only to discover their actual cost was under $50 after combining manufacturer assistance with proper insurance coordination. The key is understanding your benefit structure before the first dose and having all assistance programs in place. Don't assume your first cost estimate is final—there are usually multiple ways to reduce expenses for patients who qualify."

Managing the costs of Evkeeza requires understanding your specific Blue Cross Blue Shield benefits, maximizing available assistance programs, and knowing your rights in Ohio's appeals process. Counterforce Health specializes in helping patients navigate these complex insurance requirements, turning denials into targeted appeals with the evidence-backed documentation payers require for rare disease treatments.

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage policies vary by specific Blue Cross Blue Shield plan. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

Sources & Further Reading

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