what medicare prescription plans cover prolia

For those who meet the criteria prescribed above, Medicare Part B covers Prolia. If you don't meet the above criteria, your Medicare Part D

plan may cover the drug. GoodRx reports that 98% of surveyed Medicare prescription plans cover the drug as of October 2021.

Full Answer

Is Prolia covered by Medicare?

Prolia® is an injection administered by a healthcare professional and is covered by both Medicare Part B and Medicare Part D What you pay will depend on your Medicare plan and whether your doctor orders Prolia ® from a distributor (medical benefit) or gets it from a pharmacy (pharmacy benefit).

How much does Prolia cost without insurance?

The list price for one dose of Prolia was around $1,300 as of October 2021, according to Amgen, the manufacturer of the drug. Most people get one Prolia injection every six months, making the average cost for one year of treatment with no insurance or Medicare coverage around $2,600.

Why is Prolia so expensive?

– It is a very costly therapy: 2000 US dollar per year at present pricing – and once a patient is hooked to it he/ she must take it for at least five years (10 shots, US $ 10,000/ Besides, the manufacturers will have full freedom to steadily or steeply raise the price given the very exclusive (one may say monopolistic) character of Prolia trade. So it is not really meant for patients with limited income unless they want to depend on affluent relatives to bear the escalating cost for ...

What does Medicare really cover?

Medicare covers up to 100 days of part-time daily care or intermittent care if medically necessary. You must have spent at least three consecutive days as a hospital inpatient within 14 days of receiving home health care. If you don’t qualify for home health care coverage under Part A, you might have Medicare coverage under Part B.

Is Prolia covered under Medicare Part B or D?

For those who meet the criteria prescribed above, Medicare Part B covers Prolia. If you don't meet the above criteria, your Medicare Part D plan may cover the drug. GoodRx reports that 98% of surveyed Medicare prescription plans cover Prolia. With Medicare Part D coverage, you're likely to pay coinsurance or a copay.

Do Medicare Advantage plans cover Prolia?

Yes! 99% of Medicare Advantage plans and Medicare Part D plans cover Prolia.

What tier is Prolia injection?

What drug tier is Prolia typically on? Medicare prescription drug plans typically list Prolia on Tier 4 of their formulary. Generally, the higher the tier, the more you have to pay for the medication.

Is there a generic for Prolia?

Prolia and Reclast are both brand-name drugs. Reclast is available as the generic drug zoledronic acid, and Prolia is available as the biosimilar medication called denosumab. A generic drug is an exact copy of the active drug in a brand-name medication.

Is Prolia on the PBS?

The PBAC recommended listing of denosumab as an Authority required (Streamlined) benefit as the sole PBS-subsidised anti-resorptive agent for osteoporosis to include both male and female patients....Recommended listing.Condition/Indication:OsteoporosisRestriction:Authority required (STREAMLINED)3 more rows

Does Medicare require prior authorization for Prolia?

All requests for Xgeva (denosumab), Prolia (denosumab) require a prior authorization and will be screened for medical necessity and appropriateness using the criteria listed below.

How often will Medicare pay for Prolia injections?

The majority of commercial and Medicare plans cover Prolia®. The list price for Prolia® is $1,434.14* ,† per treatment every six months. Most patients do not pay the list price. Your actual cost will vary.

How many years should you take Prolia?

In studies, people have safely taken Prolia for up to 8 years. If the drug is working to improve your condition, your doctor may have you take it long term. They'll discuss with you the long-term benefits of Prolia and how long you should continue treatment.

How do I bill for Prolia injection?

The administration of denosumab, when billed, should be billed using the therapeutic administration code 96372 (Therapeutic prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

How much does Prolia cost at Walmart?

For every 1, 1ML of 60MG/ML Solution Prefilled Syringe, the average retail price of Prolia is around $1,780.1....Average 12 Month Prices for Prolia.PharmacyProlia Retail PriceProlia SingleCare PriceWalmart$1641.98$1395.33Walgreens$1737.53$1470.084 more rows

Does Medicare cover Prolia or Reclast?

Injectable Drugs Coverage These medications may include ibandronate (Boniva), zoledronic acid (Reclast), denosumab (Prolia) and sometimes calcitonin (Miacalcin). You will owe a 20% coinsurance payment for the Medicare-approved cost of injectable drugs, and the Part B deductible applies.

Does Medicare pay for osteoporosis treatment?

Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. help pay for an osteoporosis injectable drug and visits by a home health nurse to inject the drug if you meet these conditions: You're a woman.

What is the average cost of Prolia?

The majority of commercial and Medicare plans cover Prolia®. The list price for Prolia® is $1,434.14* ,† per treatment every six months. Most patients do not pay the list price.

Who qualifies for Prolia?

Prolia is approved only for specific types of patients: Postmenopausal women with osteoporosis and high risk of fracture (that is, previous fracture due to osteoporosis or multiple fracture risk factors). Patients with osteoporosis for whom other osteoporosis treatments have failed.

How many years should you take Prolia?

In studies, people have safely taken Prolia for up to 8 years. If the drug is working to improve your condition, your doctor may have you take it long term. They'll discuss with you the long-term benefits of Prolia and how long you should continue treatment.

Does Medicare cover bone density shots?

Medicare covers bone density screening under Part B (medical insurance) every 24 months (or more often if medically necessary) as long as you meet one or more specific conditions, outlined by Medicare.gov.

What is the drug name for Prolia?

Learn more about Prolia and find Medicare Advantage plans in your area that cover prescription drugs. Prolia ®. Chemical name: Denosumab. Typical dosage: 60mg/ml. Typical type: Injection 1. Prolia ® is typically used to help treat osteoporosis in men and in women who are at increased risk for weakened bones after menopause.

How often is Prolia given?

Prolia is typically given every six months and works to both treat and prevent osteoporosis. Prolia works by inhibiting the activation of osteoclasts, which is what breaks down bones in osteoporosis. Some common side effects of Prolia can include cold or flu symptoms such as fever, sore throat and chills.

How much is the Medicare deductible?

Some Medicare prescription drug plans have a $0 deductible. Medicare drug plans cannot have a deductible more than $415 in 2019. After you meet your Part D deductible, you enter the initial coverage period.

Can you get pregnant after stopping Prolia?

Do not become pregnant for 5 months after you stop taking it. Make sure you get plenty of calcium and vitamin D while taking Prolia (unless otherwise directed by your doctor). You may be at increased risk for infection while taking Prolia. Avoid people who are sick while taking this drug.

Does Medicare cover Prolia?

Medicare prescription drugs plans each have their own formulary, or drug list, that details what prescription drugs are covered by the plan and how they are covered. Drug coverage may vary based on plan availability. You may be able to find Medicare Advantage plan options in your area that cover Prolia.

How does Prolia work?

The result is that your bones can become brittle and can break more easily. Prolia works by preventing the development of cells that remove old bone. The drug is administered as a twice-a-year injection that is administered under one’s upper arm, upper thigh or abdomen.

How much is Medicare Part B deductible in 2021?

You must meet your Medicare Part B deductible ( $203 per year in 2021) before Medicare will pay its share. You can also consider enrolling in a Medicare Part D prescription drug plan to get help paying for some of your prescription drugs.

Does Medicare cover Prolia?

If Medicare covers your Prolia treatment, you will typically be required to pay certain Medicare out-of-pocket costs.

What tier is Prolia?

Tier 4. Medicare prescription drug plans typically list Prolia on Tier 4 of their formulary. Generally, the higher the tier, the more you have to pay for the medication. Most plans have 5 tiers.

What is prior authorization for Medicare?

Most Medicare prescription drug plans have prior authorization rules that will require your prescriber to contact your plan before you can get your medication. This is to show that the drug is medically necessary.

What is the donut hole in Medicare?

In the Donut Hole (also called the Coverage Gap) stage, there is a temporary limit to what Medicare will cover for your drug. Therefore, you may pay more for your drug. In the Post-Donut Hole (also called Catastrophic Coverage) stage, Medicare should cover most of the cost of your drug.

Is Prolia Covered by Medicare?

Prolia is often covered by Medicare. Which part of Medicare provides coverage and how much you can expect to pay out of pocket for the treatment depends on numerous factors, but Part B is usually what covers Prolia.

What Does Prolia Do?

Throughout your life, your body breaks down existing bone and builds new bone in its place to keep your skeleton strong. Osteoclasts are the cells that drive the process. As you age, the bone-building process slows down while the work of osteoclasts continues at the same pace. This leads to a loss of bone density.

How Much Does Prolia Cost Per Year?

The list price for one dose of Prolia was around $1,300 as of October 2021, according to Amgen, the manufacturer of the drug. Most people get one Prolia injection every six months, making the average cost for one year of treatment with no insurance or Medicare coverage around $2,600.

What Part of Medicare Pays for Prolia?

For those who meet the criteria prescribed above, Medicare Part B covers Prolia. If you don't meet the above criteria, your Medicare Part D plan may cover the drug. GoodRx reports that 98% of surveyed Medicare prescription plans cover the drug as of October 2021. With Medicare Part D coverage, you’re likely to pay coinsurance or a copay.

Is There a Generic Version of Prolia?

The generic name for Prolia is denosumab. As of October 2021, no generic forms of the drug have been approved by the FDA.

What Tier Is Prolia?

Your Medicare Part D plan has a formulary that spells out which drugs it covers. In the formulary, drugs are divided into the following tiers:

How Much Does Prolia Cost With Medicare?

If you qualify for coverage for Prolia under Medicare Part B, your plan will typically pay 80% of the injection while you pay the remaining 20%. Based on the list price of the drug, the 20% coinsurance would amount to roughly $250. You'll usually need to satisfy your Medicare Part B deductible before your plan will cover the drug.

What is Prolia used for?

Prolia ® is a prescription medicine used to treat bone loss in men who are at high risk for fracture receiving certain treatments for prostate cancer that has not spread to other parts of the body. Prolia ® is a prescription medicine used to treat bone loss in women who are at high risk for fracture receiving certain treatments for breast cancer ...

Does Prolia lower calcium levels?

Prolia® may lower the calcium levels in your blood. If you have low blood calcium, it may get worse during treatment. Your low blood calcium must be treated before you receive Prolia®. Take calcium and vitamin D as your doctor tells you to help prevent low blood calcium.

Can you take Prolia while pregnant?

Do not take Prolia® if you: have low blood calcium; or are pregnant or plan to become pregnant, as Prolia® may harm your unborn baby; or are allergic to denosumab or any ingredients in Prolia®.

Does Prolia cause back pain?

The most common side effects of Prolia® in men with osteoporosis are back pain, joint pain, and common cold (runny nose or sore throat). The most common side effects of Prolia® in patients with corticosteroid-induced osteoporosis are back pain, high blood pressure, lung infection (bronchitis), and headache.

Can Prolia cause muscle pain?

Bone, joint, or muscle pain. Some people who take Prolia® develop severe bone, joint, or muscle pain. Have been told you have trouble absorbing minerals in your stomach or intestines (malabsorption syndrome) Your healthcare provider should do a pregnancy test before you start treatment with Prolia®.

Can Prolia cause ear infections?

Serious infections in your skin, lower stomach area (abdomen), bladder, or ear may happen. Inflammation of the inner lining of the heart (endocarditis) due to an infection may also happen more often in people who take Prolia®. You may need to go to the hospital for treatment.

Does Prolia have an annual deductible?

Your out-of-pocket costs may vary depending on your insurance plan. Each plan has different out-of-pocket costs, and most include an annual deductible. Patients on high deductible plans may pay more out-of-pocket for Prolia ®.

What are the symptoms of Prolia?

Symptoms have included hypotension, dyspnea, throat tightness, facial and upper airway edema, pruritus, and urticaria. If an anaphylactic or other clinically significant allergic reaction occurs, initiate appropriate therapy and discontinue further use of Prolia®.

How long does it take to monitor calcium levels after Prolia?

In patients predisposed to hypocalcemia and disturbances of mineral metabolism, including treatment with other calcium-lowering drugs, clinical monitoring of calcium and mineral levels is highly recommended within 14 days of Prolia® injection.

Is Prolia contraindicated for hypocalcemia?

Contraindications: Prolia ® is contraindicated in patients with hypocalcemia. Pre-existing hypocalcemia must be corrected prior to initiating Prolia ®. Prolia® is contraindicated in women who are pregnant and may cause fetal harm. In women of reproductive potential, pregnancy testing should be performed prior to initiating treatment with Prolia®.

General Information

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Article Guidance

This article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses. Abstract: Denosumab is a receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor.

ICD-10-CM Codes that Support Medical Necessity

For the treatment of patients with bone metastases from solid tumors. Note: multiple myeloma, lymphoma and other cancers of the blood are not considered solid tumors).

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

What is original Medicare?

Your costs in Original Medicare. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

What is part A of Medicare?

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. help pay for an injectable drug for osteoporosis and visits by a home health nurse to inject the drug if you meet these conditions: ...