Will Medicare Pay For Prolia

American Hospital Association Disclaimer

The American Hospital Association has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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 Prolia. With Medicare Part D coverage, youâre likely to pay coinsurance or a copay.

When Does Medicare Pay For Prolia

Original Medicare may cover injectable osteoporosis drugs such as Prolia for women who:

• Are enrolled in Medicare Part B

• Meet Medicares requirements for getting home health services

• Have a bone fracture that is related to post-menopausal osteoporosis

• Have received a doctors certification that they are unable to administer the injection

Medicare Part B also covers bone density measurements once every 24 months if you meet one of the following conditions:

• You’re a woman determined to be estrogen deficient or at risk for osteoporosis by your doctor

• X-rays show you have possible osteoporosis, osteopenia or fractured vertebrae.

• You take prednisone or steroid-type drugs

• You have primary hyperparathyroidism.

• You’re currently taking an osteoporosis drug like Prolia

You May Like: Is Part B Medicare Required

Is Prolia Covered By Medicare

• Is Prolia covered by Medicare?’ Learn about the cost of this osteoporosis drug and how much you can expect to pay for it if your doctor prescribes it for you.

The National Osteoporosis Foundation reports that roughly 10 million Americans have osteoporosis and that an additional 44 million people suffer from decreased bone density and may develop the disease in the future. Osteoporosis puts you at an increased risk for debilitating fractures, but there are treatments available to lower the likelihood of injury due to a fall or other accident.

Prolia is approved by the U.S. Food and Drug Administration to treat bone loss and minimize fracture risk. In many cases, Medicare covers Prolia to make treatment more affordable.

Medicare Part B Step Therapy Criteria

Xgeva, for the indication listed below:

• Hypercalcemia of Malignancy

Is not covered for new starts, unless the member meets ANY of the following:

Don’t Miss: How Much Are Premiums For Medicare

Medicare Part B Drugs: Cost Implications For Beneficiaries In Traditional Medicare And Medicare Advantage

In the face of rising prescription drug costs, a large majority of the public supports federal efforts to lower drug spending. In his 2022 State of the Union address, President Biden urged Congress to pass legislation to rein in drug costs. In November 2021, the House of Representatives passed the Build Back Better Act , which includes several provisions that would lower prescription drug costs, but the Senate has yet to take action on this legislation. Proposals included in the BBBA would allow the federal government to negotiate the price of some drugs covered under Medicare Part B and Part D require drug companies to pay rebates to the federal government when annual increases in drug prices for Medicare and private insurance exceed the rate of inflation cap monthly insulin costs for people with Medicare and private insurance and cap Medicare beneficiaries out-of-pocket drug spending under Part D .

In the first part of this analysis, we examine Medicare claims data for 2019 to assess cost-sharing liability for Part B drugs for beneficiaries in traditional Medicare . In the second part of our analysis, we use Medicare Advantage benefit design data for 2022 to examine the range in cost-sharing amounts at or below 20% coinsurance charged by Medicare Advantage plans for in-network Part B drugs. We also analyze variation in cost-sharing amounts for out-of-network Part B drugs charged by plans that provide out-of-network coverage.

Is The Cost Of Prolia Covered By Medicare

Whether Prolia is covered by Medicare depends on the type of Medicare coverage you have. Many different Medicare plans are available. And Prolia may be covered under some Medicare plans but not others.

If you have a Medicare plan, contact your doctor or your Medicare plan provider. Either can let you know what youll pay for Prolia.

You May Like: Does Medicare Pay For Portable Oxygen Tanks

How Much Do Prolia Injections Cost

The price you pay for Prolia injections can vary. Your cost may depend on your treatment plan, your insurance coverage , and how much youll pay for an office visit to receive Prolia. If you have to bring the medication to your injection appointment, it may also depend on the pharmacy you use.

To find out how much youll pay for Prolia, talk with your doctor, pharmacist, or insurance provider.

Note: If you have insurance, you may need to get prior authorization before your insurance provider will cover Prolia.

This means your insurer and your doctor will discuss Prolia in regard to your treatment. Then the insurance company will determine whether the drug is covered. If Prolia requires prior authorization and you dont receive it before you start treatment, you could pay the full cost of the drug.

Be sure to ask your insurance company whether Prolia requires prior authorization.

• Medicine Assistance Tool

On these sites, you can find insurance information, details on cost assistance programs, and links to savings cards and other services.

If you have insurance, you may be eligible for copay assistance from a program called Prolia Co-pay. For more information about this copay program, visit the drugmakers website or call 844-369-9962.

If you dont have insurance, the Amgen Safety Net Foundation could cover the cost of your medication. To find out if youre eligible for assistance, go to the ASNF website or call 866-264-2778.

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:

• Tier 1: The cheapest generic drug for a specific condition
• Tier 2: Other generic drugs for that condition
• Tier 3: The cheapest brand name drug that treats the condition and has no generic equivalent
• Tier 4: Other brand name drugs for the condition
• Tier 5: Experimental or specialty drugs for a condition

Because Prolia is a brand name drug with no generic equivalent, it typically falls under Tier 3 or 4. Consult your Medicare prescription drug plan’s formulary for more information.

Also Check: What Is Part B Excess Charges In Medicare

Systemic Mastocytosis And Osteopenia/osteoporosis

Systemic mastocytosis is a heterogeneous disorder in which mast cells accumulate and infiltrate one or more extracutaneous organs , with or without skin involvement. One of the major diagnostic criterion, per the World Health Organization , includes multifocal, dense infiltrates of mast cells greater than or equal to 15 mast cells in aggregates detected in the biopsy sections of bone marrow and/or other extracutaneous organs. SM can be further divided into 5 diferent clinical subtypes . Signs and symptoms of mast cell activation in systemic mastocytosis includes bone pain, osteopenia and osteoporosis, which are the most common bone complications in patients with SM . Individuals with all forms of SM should be monitored for osteoporosis and treated appropriately .

Dont Miss: Is Goodrx Better Than Medicare Part D

Compendial Uses For Prolia

• Prevention or treatment of osteoporosis during androgen deprivation therapy for prostate cancer in patients with high fracture risk
• Consider in postmenopausal patients receiving adjuvant aromatase inhibition therapy along with calcium and vitamin D supplementation to maintain or improve bone mineral density and reduce risk of fractures

Read Also: Does Medicare Pay For Air Evac

Recommended Reading: How Do I Register For Medicare Part A

What Is The Alternative To Taking Prolia

The FDA has approved another brand-name version of denosumab, called Xgeva. Your Medicare Part D plan might not cover the medication. If it does, your out-of-pocket price for Xgeva injections may cost more or less than Prolia, depending on where the drugs are classified on the formulary.

Instead of Prolia, doctors may prescribe other drugs for people at risk of suffering fractures due to osteoporosis, such as:

• Bisphosphonates like alendronate, ibandronate, risedronate and zoledronic acid
• Bone-building medications like teriparatide, abaloparatide and romosozumab
• Hormone-related therapy like raloxifene

When Will Prolia Go Generic

The patents on the originator product for Denosumab, Amgen’s Prolia, will expire in the U.S. in February 2025 and in Europe in June 2022, except for France, Italy, Spain and the U.K., which expire in 2025. There are currently five drug companies6 reported with ongoing clinical development of Denosumab biosimilar.

Also Check: When Is The Last Day To Change Medicare Plans

Other Medicare Coverage For Osteoporosis

To help learn if youre at risk for broken bones and osteoporosis, Medicare Part B covers a bone mass measurement test once every 24 months. To qualify, you must meet one of the following conditions:

• Be a woman whose doctor determines youre estrogen-deficient and at risk for osteoporosis
• Your x-rays show possible osteoporosis, osteopenia, or vertebral fractures

Additionally, you qualify if youre taking prednisone or steroid-type drugs , youve been diagnosed with primary hyperparathyroidism, or youre being monitored to see if your osteoporosis drug therapy is working.

You would pay $0 for this test as long as the doctor accepts Medicare assignment.

Is Prolia Covered By Medicare 2019

by Sharon Groves | Mar 19, 2019 | The American Retirement Advisor Blog

There is an antibody in Prolia that slows down the weakening of bones. It signals the cells that break bone down, preventing these cells from forming. The FDA has approved twice-a-year Prolia injections to treat osteoporosis in people with a high risk of fractures. It is usually administered to the patient in a doctors office.

Possible side effects include serious allergic reactions, low blood calcium, severe jaw bone problems, unusual thigh bone fractures, and increased risk of broken bones. After stopping Prolia, serious infections, skin problems, and bone, joint, or muscle pain, can occur.

Foods that increase bone density are milk, cheese, dairy foods, green leafy vegetables, broccoli .

Prolia is administered in your doctors office or a medical clinic. The drug could be considered a covered item under Medicare Part B if Medicare determines the drug is medically necessary. Pre-authorization is required before Medicare will pay for your treatment.

Medicare Part A and Medicare Part B help pay for an injectable drug for osteoporosis and visits by a home health nurse to inject the drug, if you meet these conditions:

1)Youre a woman.

2) Youre eligible for Part B and meet the criteria for Medicare home health services.

See Medicare.gov.

You have a bone fracture that a doctor certifies is related to postmenopausal osteoporosis.

Don’t Miss: How Much Is Medicare And Medicaid

Medicare Part C Inpatient Coverage

The inpatient coverage youll receive with Medicare Part C will at least match those of Medicare Part A. These services include:

• inpatient hospital care

• vaccinations for flu, hepatitis B, and pneumococcal disease

Any additional coverage for these services will be outlined by the specific plan you choose. For example, some plans offer basic vision exams, while others include allowances for prescription eyeglasses or contact lenses.

The cost of a Medicare Part C plan will depend on a variety of factors. The most common costs within your plan will be:

• your Part B monthly premium, which may be covered by your Part C plan
• your Medicare Part C costs, which include a deductible and monthly premiums
• your out-of-pocket costs, which include copayments and coinsurance

Below are some cost comparisons for Medicare Part C plans in some major cities around the United States. All the plans listed below cover prescription drugs, vision, dental, hearing, and fitness benefits. However, they all differ in cost.

Lower Medicare Advantage Premiums

Medicare Advantage plans are administered by private insurers. Premiums vary, but the average rate is dropping to $18 a month. The premium for Medicare Advantage plans is in addition to the Part B premium, which everyone pays . Some insurers advertise zero-premium plans, but this refers to the additional Medicare Advantage premium these plans are allowed to charge. People who enroll in a zero-premium Medicare Advantage plan will still need to pay the Part B premium.

Read Also: What Do The Different Parts Of Medicare Cover

Does Your Medicare Insurance Plan Cover Prolia

Osteoporosis is a common condition in the United States. Over 10 million people have osteoporosis, and 44 million have bone density levels that are well below normal. People with osteoporosis live with limited mobility, pain, loss of height, and fear of bone fractures daily.

What Is Osteoporosis, and Are You At Risk?

Taken from the Greek language, osteoporosis means porous bones. It is a condition that promotes bone tissue deterioration and leads to brittle, fragile bones that are at greater than normal risk of cracking, breaking, or compressing under pressure. While there is no cure for osteoporosis, there are treatments that can help by slowing bone deterioration. They can help protect and strengthen bones, and even in some cases, stimulate new bone growth.

Osteoporosis is called a silent disease because there are typically no symptoms until you get a broken bone. The most common fractures occur in the hip, wrist, spine and shoulder.

The human body contains specific cells that are bone producing cells, and other cells that are bone removing cells. When this process is working normally, there is a continuous process of breaking down and building up of bone tissue, resulting in strong, healthy bones. In post-menopausal osteoporosis, the bone removing cells are more active which means the rate of bone loss is greater than the rate of bone building, resulting in brittle bones.

Dont Miss: When Do Medicare Benefits Kick In

Is There A Manufacturer Coupon Available For Prolia

No, currently there isnt a manufacturer coupon available for Prolia.

But if you have insurance, the drugmaker has a Prolia copay card that could help lower the cost of copays.

This copay card is available through the drugmakers Prolia Co-pay Program. For information about this program, refer to the Can I get help paying for Prolia, such as a copay card? section above. The section also has a few other resources that may help you save on the cost of Prolia, regardless of whether you have insurance.

Don’t Miss: What Is The Donut Hole In Medicare Prescription Coverage

Before Using This Medicine

You should not use Prolia if you are allergic to denosumab, or if you have low levels of calcium in your blood .

While you are using Prolia, you should not use Xgeva, another brand of denosumab.

To make sure Prolia is safe for you, tell your doctor if you have:

• a history of thyroid surgery

• a history of surgery to remove part of your intestine

• any condition that makes it hard for your body to absorb nutrients from food or

• if you are allergic to latex.

Prolia may cause bone loss in the jaw. Symptoms include jaw pain or numbness, red or swollen gums, loose teeth, gum infection, or slow healing after dental work.

Osteonecrosis of the jaw may be more likely if you have cancer or received chemotherapy, radiation, or steroids. Other risk factors include blood clotting disorders, anemia , and a pre-existing dental problem.

Prolia can harm an unborn baby or cause birth defects. Do not use Prolia if you are pregnant. Tell your doctor right away if you become pregnant during treatment.

It is not known whether denosumab passes into breast milk or if it could harm a nursing baby. This medicine may also slow the production of breast milk. You should not breast-feed while using this medicine.

Denosumab For The Treatment Of Aneurysmal Bone Cyst

The authors stated that it should be clearly noted that the role of denosumab in ABCs could not be concluded with certainty, owing to various drawbacks in the available literature. Such drawbacks include the weak study design in terms of sample size and study type. To elaborate further, the vast majority of studies were isolated single-case reports, and even the retrospective cohort series included only a few patients and such studies further lacked a valid control group. Moreover, to-date, there are no RCTs that inform about highly trustworthy and strong evidence-based medicine. This could be largely attributed to that fact that the use of denosumab in the management of ABCs continues to be off-label and not yet green-lighted by the FDA. Additional drawbacks included variations in age of ABC populations treated with denosumab as well as the diverse dosing schedules of denosumab. With respect to survival and end-point outcomes, the short duration of follow-up limited the prospect to draw concrete conclusions about short- and long-term safety, efficacy, and loco-regional relapse. Lastly, the presence of diverse hidden confounding factors may have directly or indirectly influenced the true clinical/radiological outcomes in patients with ABCs.

Recommended Reading: How Do I Apply For Medicare When I Turn 65

More Information Regarding Prescription Drugs

Transitioning to a New Plan Policy

Medication Therapy Management

Cigna Medicare Advantage Plans

Cigna Secure Rx Plan

Cigna Essential Rx Plan PDP

Cigna Extra Rx Plan

Cigna Medicare Advantage Plans

Cigna Medicare Advantage Plans Part B Drugs

Cigna Secure Rx Plan

Cigna Essential Rx Plan

Cigna Extra Rx Plan

License For Use Of Physicians’ Current Procedural Terminology Fourth Edition

End User Point and Click Amendment:CPT codes, descriptions and other data only are copyright 2021 American Medical Association. American Medical Association. All Rights Reserved . CPT is a trademark of the American Medical Association .

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of CMS internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services . You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, .

Also Check: Is Wellcare The Same As Medicare