Prolia® is a prescription medicine used to treat osteoporosis in women after menopause who are at high risk for fracture or cannot use another osteoporosis medicine or other osteoporosis medicines did not work well. Prolia® is a prescription medicine used to increase bone mass in men with osteoporosis who are at high risk for fracture.
Full Answer
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.
How does Medicare cover Prolia?
Medicare plans typically list Prolia in Tier 4 of their formulary. You pay 20% of the Medicare-approved amount for the cost of the drug, and the Part B deductible applies. You pay nothing for the home health nurse visit to inject the drug. To find out how much your test, item, or service will cost, talk to your doctor or health care provider.
Does your Medicare insurance plan cover Prolia?
Yes! 99% of Medicare Advantage plans and Medicare Part D plans cover Prolia. 1 Medicare Advantage plans that offer prescription drug coverage are called Medicare Advantage Prescription Drug Plans (MA-PD). Most Medicare Advantage beneficiaries ( 88 percent) are enrolled in MA-PDs. 2
Does Medicare cover Prolia for osteopenia?
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.
Is Prolia covered under Medicare Part B or D?
Dual eligible patients: Medicare Part D is the primary source of drug coverage for “dual eligible” beneficiaries covered under both Medicare and Medicaid. *Access is defined as the ability of a patient to obtain Prolia®, although patient OOP cost and insurance requirements may vary.
Does Medicare cover Prolia for osteoporosis?
Yes. 97% of Medicare prescription drug plans cover this drug.
Is there a patient assistance program for Prolia?
Amgen Safety Net Foundation 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®.
How much should a Prolia shot cost?
Prolia prices without insurance will vary depending on where you buy it, but you can expect to pay around $2,560 for a single 60 ml/mg syringe of Prolia.
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 $1,829.7....Average 12 Month Prices for Prolia.PharmacyProlia Retail PriceProlia SingleCare PriceWalmart$1689.97$1429.68Walgreens$1768.76$1496.404 more rows
What is the best alternative to Prolia?
These include:Alendronate (Fosamax), a weekly pill.Risedronate (Actonel), a weekly or monthly pill.Ibandronate (Boniva), a monthly pill or quarterly intravenous (IV) infusion.Zoledronic acid (Reclast), an annual IV infusion.
How long does it take for Prolia to improve bone density?
They reported that “denosumab (Prolia in 14, 60, and 100 mg doses) showed significant increases in percent BMD (bone mineral density) values of lumbar spine and total hip from baseline in 12 months.
Can I stop Prolia after 3 years?
Researchers and physicians recommend that you do not stop taking Prolia without making a plan for further bone treatment.
What is better than Prolia for osteoporosis?
My doctor has suggested a few alternatives. Any thoughts on what might be best? ANSWER: Oral bisphosphonate drugs — including alendronate (Fosamax), risedronate (Actonel and Atelvia) and ibandronate (Boniva) — are the most commonly prescribed osteoporosis drugs.
Is taking 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.
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.
Can a pharmacist give a Prolia shot?
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.
How long can you take Prolia for osteoporosis?
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.
What is better than Prolia for osteoporosis?
My doctor has suggested a few alternatives. Any thoughts on what might be best? ANSWER: Oral bisphosphonate drugs — including alendronate (Fosamax), risedronate (Actonel and Atelvia) and ibandronate (Boniva) — are the most commonly prescribed osteoporosis drugs.
How is osteoporosis covered by Medicare?
They can also help you find out how well an osteoporosis medication is working. 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.
How often is bone density covered by Medicare?
once every 24 monthsBone mass measurements covers this test once every 24 months (or more often if medically necessary) if you meet one of more of these conditions: You're a woman whose doctor determines you're estrogen-deficient and at risk for osteoporosis, based on your medical history and other findings.
If you have commercial insurance
The Amgen FIRST STEP™ Program can help eligible commercially insured patients meet their deductible, co-insurance, or co-payment. ‡
If you have government insurance like Medicare
Amgen Assist 360™ can refer patients to independent nonprofit patient assistance programs that may be able to help them afford the co-pay costs for their prescribed medicine. †
For uninsured patients
Amgen Safety Net Foundation is a nonprofit patient assistance program sponsored by Amgen that helps qualifying patients access Amgen medicines at no cost.
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®.
What is atypical femoral fracture?
Atypical Femoral Fractures: Atypical low-energy, or low trauma fractures of the shaft have been reported in patients receiving Prolia®. Causality has not been established as these fractures also occur in osteoporotic patients who have not been treated with antiresorptive agents.
Can you get multiple vertebral fractures after Prolia?
Multiple Vertebral Fractures (MVF) Following Discontinuation of Prolia® Treatment: Following discontinuation of Prolia ® treatment, fracture risk increases, including the risk of multiple vertebral fractures. New vertebral fractures occurred as early as 7 months (on average 19 months) after the last dose of Prolia ®. Prior vertebral fracture was a predictor of multiple vertebral fractures after Prolia ® discontinuation. Evaluate an individual’s benefit/risk before initiating treatment with Prolia ®. If Prolia ® treatment is discontinued, patients should be transitioned to an alternative antiresorptive therapy.
Does Prolia cause hypocalcemia?
Hypocalcemia: Hypocalcemia may worsen with the use of Prolia®, especially in patients with severe renal impairment. 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. Concomitant use of calcimimetic drugs may worsen hypocalcemia risk and serum calcium should be closely monitored. Adequately supplement all patients with calcium and vitamin D.
Can you get serious infections while on Prolia?
In patients who develop serious infections while on Prolia®, prescribers should assess the need for continued Prolia ® therapy.
Does Medicare Part D cover Prolia?
80% of Medicare Part D patients with access* to Prolia ® have no step edit, meaning it is available as an initial therapy option. 1,†
Can you get ONJ with Prolia?
Osteonecrosis of the Jaw (ONJ): ONJ, which can occur spontaneously, is generally associated with tooth extraction and/or local infection with delayed healing, and has been reported in patients receiving Prolia®. An oral exam should be performed by the prescriber prior to initiation of Prolia®. A dental examination with appropriate preventive dentistry is recommended prior to treatment in patients with risk factors for ONJ such as invasive dental procedures, diagnosis of cancer, concomitant therapies (e.g., chemotherapy, corticosteroids, angiogenesis inhibitors), poor oral hygiene, and co-morbid disorders. Good oral hygiene practices should be maintained during treatment with Prolia®. The risk of ONJ may increase with duration of exposure to 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.
What is atypical femoral fracture?
Atypical Femoral Fractures: Atypical low-energy, or low trauma fractures of the shaft have been reported in patients receiving Prolia®. Causality has not been established as these fractures also occur in osteoporotic patients who have not been treated with antiresorptive agents.
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®.
Does Medicare Part B cover Prolia?
of Medicare Part B patients have access † to Prolia ® as an initial therapy 1,‡
Can you get serious infections while on Prolia?
In patients who develop serious infections while on Prolia®, prescribers should assess the need for continued Prolia ® therapy.
Can Prolia cause muscle pain?
Musculoskeletal Pain: Severe and occasionally incapacitating bone, joint, and/or muscle pain has been reported in patients taking Prolia®. Consider discontinuing use if severe symptoms develop.
Fulfill Through Buy & Bill
Find resources and support for offices that purchase Prolia ® through authorized wholesalers (or schedule treatment at alternate sites of care).
Fulfill Through Pharmacy
Explore resources and support for offices that obtain Prolia ® through a retail or specialty pharmacy.
Referrals to Independent Co-pay Foundations
Amgen Assist ® can refer patients, as a courtesy, to independent co-pay foundations.*
Referrals to Amgen Safety Net Foundation
Amgen Safety Net Foundation 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 ®.
For patients with government insurance like Medicare
We provide referrals to independent nonprofit patient assistance programs that may be able to help them afford the co-pay cost of their medicine.**
For uninsured patients
Amgen Safety Net Foundation is a nonprofit patient assistance program sponsored by Amgen that helps qualifying patients access Amgen medicines at no cost.
What is the best treatment for osteoporosis?
If you are a post-menopausal woman who has osteoporosis, your physician may suggest taking Prolia. Prolia, or the generic denosumab, is a prescribed injectable medication can be prescribed for post-menopausal women to reduce the incidence of vertebral, non-vertebral, or hip fractures.
What is the deductible for Medicare Part B injections?
If you are eligible, Medicare covers 80 percent of the Medicare approved cost. You must also pay the deductible for Medicare Part B which is $185.00 in 2019.
Does Prolia help with osteoporosis?
It can also be prescribed to increase bone mass in men with osteoporosis. Prolia helps bones retain mass and strength. It is worth your time to find out more about whether your Medicare insurance plan pays for treatment, if you are eligible, what to expect from this treatment, and if Prolia is right for you.
Does Prolia require prior authorization?
Through Medicare Part D, Prolia is covered for approximately 95 percent of its beneficiaries, 50 percent of whom do not need prior authorization. Because this coverage depends on your individual medical benefit coverage plan, it is best to discuss the details with your plan and your physician. Related articles:
Does Medicare cover osteoporosis?
Original Medicare Part A and Part B may cover 80 percent of the cost of injectable medications for osteoporosis if you are a post-menopausal female and comply with the criteria for home health services. You must also meet the following requirements to be eligible:
How Much Does Prolia Cost With Medicare?
If Medicare does cover your Prolia shots, you’ll likely pay 20% of Medicare’s approved cost of the drug.
What is Medicare Supplement Insurance?
Medicare Supplement Insurance (Medi gap) plans help cover some of Medicare's out-of-pocket costs, including at least partial coverage for:
What are the requirements for home health care?
Meet Medicare’s requirements for getting home health services. Have a bone fracture that is related to post-menopausal osteoporosis. Have received a doctor’s certification that they (or their caretaker) are unable to administer the injection.
Does Medicare cover Prolia?
If Medicare covers your Prolia treatment, you will typically be required to pay certain Medicare out-of-pocket costs.
What is Prolia used for?
Prolia (denosumab) is a member of the miscellaneous bone resorption inhibitors drug class and is commonly used for Osteoporosis.
What is the Prolia Amgen first step program?
Prolia Amgen First Step Program: Eligible commercially insured patients may save on their out-of-pocket medication costs; for additional information contact the program at 888-427-7478.
What is the HCPCS code for Prolia?
HCPCS code J0897 should be used to report denosumab (Prolia™, Xgeva™) for claims submitted to the Part A and Part B MAC.
Is the ADA a third party beneficiary?
The ADA is a third party beneficiary to this Agreement.
Can you use CPT in Medicare?
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 (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Does CMS have a CDT license?
Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.
