Are prolia shots covered by Medicare?

Asked by: Wanda Kub  |  Last update: February 9, 2022
Score: 4.8/5 (28 votes)

The majority of commercial and Medicare plans cover Prolia®. The list price for Prolia® is $1,278.79* , per treatment every six months. Most patients do not pay the list price. Your actual cost will vary.

Does Original Medicare cover Prolia injections?

Do Medicare prescription drug plans cover Prolia? Yes. 98% of Medicare prescription drug plans cover this drug.

Are Prolia injections covered under Medicare Part B?

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.

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 do I bill Medicare 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.

Medications Not Covered by Medicare

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What is the generic name for Prolia?

Denosumab is the generic name for the trade name drugs Prolia® or Xgeva®. In some cases, health care professionals may use the trade names Prolia® or Xgeva® when referring to the generic drug name denosumab. Prolia® and Xgeva® are the same generic drug (denosumab).

What drug class is Prolia?

Denosumab belongs to a class of drugs called monoclonal antibodies. It prevents certain cells in the body (osteoclasts) from breaking down bone.

How can I get Prolia for free?

Amgen Safety Net Foundation (ASNF) is an independent, nonprofit patient assistance program that provides Prolia® at no cost to qualifying patients who have a financial need and who are uninsured or have insurance that excludes Prolia®.

Does Prolia cause weight gain?

Weight gain itself wasn't reported as a side effect during clinical trials of Prolia. However, some people taking Prolia did have swelling in their arms or legs. And with swelling, your body weight can be quickly increased.

Is Prolia worth the risk?

Are there any dangers of using this drug? Studies have found that Prolia is generally safe and effective to treat osteoporosis and certain types of bone loss. For example, in the studies, people taking Prolia for up to 8 years didn't have significant side effects compared with people taking a placebo.

Where can I get a Prolia injection?

Prolia ® can be obtained through a specialty pharmacy or retail pharmacy: Pharmacy fills the prescription. Patient pays cost-sharing under the pharmacy benefit or Medicare Part D. Patient brings their Prolia ® to your office or treatment site for injection by a healthcare provider.

What is the safest injection for osteoporosis?

Denosumab injection (Prolia) is used

to treat men who have an increased risk for fractures (broken bones) or who cannot take or did not respond to other medication treatments for osteoporosis.

Is Fosamax the same as Prolia?

Is Fosamax the same as Prolia? Fosamax is not the same as Prolia. Both belong to different groups of osteoporosis medications and work in different ways to treat and prevent osteoporosis.

Is Forteo covered by Medicare Part D?

Do Medicare prescription drug plans cover Forteo? Yes. 93% of Medicare prescription drug plans cover this drug.

Can Prolia be given at home?

The current U.S. Prescribing Information states that Prolia® (denosumab) should be administered by a healthcare provider. At this time, self-administration of Prolia® is not approved in the United States.

How long has Prolia been on the market?

But the FDA approved Amgen's Prolia (denosumab) in 2010 to prevent fractures in women with osteoporosis, two months earlier than expected.

Does Prolia affect your teeth?

Dental side effect of receiving Prolia

Prolia has a side effect in patients who have to have tooth extractions performed. The trauma of the extraction on the bone surrounding the tooth may lead to a condition where the bone dies off, and following the extraction fragments of dead bone are lost from the extraction site.

Can you have dental work while on Prolia?

Older women who received denosumab (Prolia, Amgen) for up to 10 years for osteoporosis had a low risk of osteonecrosis of the jaw (ONJ), although the risk was higher — albeit still quite small — if they had had major dental work, researchers report.

Can Prolia cause hair loss?

Does Prolia cause hair loss? In studies, people using Prolia didn't report hair loss as a side effect. However, hair loss has been reported by people using Prolia after these studies.

What is the cost of one Prolia injection?

This is a brand name drug and a generic may be available. The average cost for 1 Syringe, 1ml of 60mg/ml each, is $1,793.09. You can buy Prolia at the discounted price of $1,438.41 by using the WebMDRx coupon, a savings of 20%. Even if this drug is covered by Medicare or your insurance, we recommend you compare prices.

What is the annual cost of Prolia?

While generic Fosamax costs roughly $100 to $200 per year and brand-name bisphosphonates slightly less than $1,000 per year, Prolia will cost about $1,650 per year plus the cost associated with an office visit. Prolia is also more expensive than Reclast, which costs $1,100 for a yearly dose.

Is Boniva the same as Prolia?

Prolia (denosumab) and Boniva (ibandronate) are used to prevent and treat bone loss (osteoporosis) in women who are at high risk for bone fracture after menopause. Prolia and Boniva belong to different drug classes. Prolia is a monoclonal antibody and Boniva is a bisphosphonate.

Do you need to take vitamin D with Prolia?

You should take calcium and vitamin D as your doctor tells you to while you receive Prolia®. After your treatment with Prolia® is stopped, or if you skip or delay taking a dose, your risk for breaking bones, including bones in your spine, is increased.

How much vitamin D should I take with Prolia?

Administer Prolia via subcutaneous injection in the upper arm, the upper thigh, or the abdomen. All patients should receive calcium 1000 mg daily and at least 400 IU vitamin D daily [see WARNINGS AND PRECAUTIONS].

Why you should not take Prolia?

People with weakened immune systems are advised not to use to denosumab because it can lead to serious infections that require hospitalization (such as heart infections). It can also cause disintegration of the jaw, called osteonecrosis, and atypical femur fractures.