Is Prolia Covered by Medicare? What You Need to Know Before You Get This Injection

Is Prolia covered by Medicare?In this article, you will learn how Medicare covers Prolia and how much you can expect to pay.
Is Prolia covered by Medicare?In this article, you will learn how Medicare covers Prolia and how much you can expect to pay.

Prolia is a prescription drug that is used to treat osteoporosis, a condition that causes bones to become weak and brittle.

Prolia works by blocking a protein that breaks down bone tissue, and helps to prevent fractures and increase bone density.

It is given as an injection under the skin every six months by a health care provider.

But is Prolia covered by Medicare, and how much does it cost?

In this article, we will answer these questions and provide you with the latest information on Prolia coverage and pricing in 2024.

Medicare Coverage for Prolia

An infographic on Medicare Coverage for Prolia Medicare Coverage for Prolia
An infographic on Medicare Coverage for Prolia Medicare Coverage for Prolia

The good news is that most Medicare plans cover Prolia and other osteoporosis injectable drugs.

However, the coverage and costs may vary depending on which part of Medicare you have and where you get the drug.

Medicare Part B

Medicare Part B (Medical Insurance) covers Prolia if you meet the following criteria:

If you meet these criteria, Medicare Part B will pay 80% of the Medicare-approved amount for Prolia, and you will pay the remaining 20% coinsurance.

The Medicare-approved amount for Prolia is $1,624.54 per injection in 2024.

This means that you will pay about $325 per injection every six months, plus any deductible or copayment that applies to your Part B plan.

Medicare Part B also covers the cost of the home health nurse visit to inject the drug, if you are homebound and your doctor orders it.

You will pay nothing for the home health nurse visit.

Medicare Part D

Medicare Part D (Prescription Drug Coverage) may also cover Prolia, if you have a stand-alone Part D plan or a Medicare Advantage plan that includes Part D.

However, the coverage and costs may vary depending on your plan and the pharmacy you use.

To find out if your Part D plan covers Prolia, you can check the plan’s formulary, which is a list of drugs that the plan covers and how much they cost.

You can also contact your plan directly and ask about Prolia coverage and pricing.

Generally, Part D plans place drugs into different tiers, with different costs for each tier.

Prolia is usually placed in a higher tier, which means that you will pay more for it than for generic or lower-tier drugs.

You may also have to pay a deductible, copayment, or coinsurance, depending on your plan.

The average cost of Prolia under Part D plans in 2024 is $1,736.63 per injection.

This means that you will pay about $347 per injection every six months, plus any deductible or copayment that applies to your Part D plan.

Medicare Supplement

Medicare Supplement (Medigap) is a type of private insurance that helps pay for some of the out-of-pocket costs that Original Medicare (Part A and Part B) does not cover, such as deductibles, coinsurance, and copayments.

If you have a Medicare Supplement plan, it may help pay for some of the costs of Prolia that Part B does not cover, such as the 20% coinsurance.

However, Medicare Supplement plans do not cover any of the costs of Part D plans, such as deductibles, copayments, or coinsurance.

Therefore, if you get Prolia through a Part D plan, you will still have to pay those costs yourself.

To find out how much your Medicare Supplement plan will pay for Prolia, you can check your plan’s benefits, or contact your plan directly and ask about Prolia coverage and pricing.

How to Save Money on Prolia

An infographc on How to Save Money on Prolia
An infographc on How to Save Money on Prolia

Prolia can be an expensive drug, even with Medicare coverage. However, there are some ways to save money on Prolia, such as:

  • Comparing different Medicare plans and choosing the one that covers Prolia and has the lowest costs for you. You can use the Medicare Plan Finder tool to compare plans and costs in your area.
  • Asking your doctor or pharmacist if there are any generic or lower-cost alternatives to Prolia that may work for you. Prolia is a brand-name drug, and there are no generic versions available yet. However, there may be other osteoporosis drugs that are cheaper and equally effective for you.
  • Applying for financial assistance programs that may help pay for some or all of the costs of Prolia. There are several programs that may help you, such as:
    • The Medicare Extra Help program, which helps pay for some or all of the costs of Part D plans, such as premiums, deductibles, copayments, and coinsurance. You may qualify for this program if you have a low income and limited assets. You can apply for this program through the Social Security Administration or your state Medicaid office.
    • The Prolia Co-Pay Program, which helps pay for some or all of the out-of-pocket costs of Prolia for eligible patients with commercial or Medicare insurance. You may qualify for this program if you have a valid prescription for Prolia and meet certain income and insurance criteria. You can apply for this program through the Prolia website or by calling 1-844-369-9964.
    • The Patient Advocate Foundation Co-Pay Relief Program, which helps pay for some or all of the out-of-pocket costs of Prolia for eligible patients with Medicare or other insurance. You may qualify for this program if you have a diagnosis of osteoporosis, a valid prescription for Prolia, and meet certain income and insurance criteria. You can apply for this program through the Patient Advocate Foundation website or by calling 1-866-512-3861.

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Conclusion

Prolia is a drug that is used to treat osteoporosis and prevent fractures.

It is covered by most Medicare plans, but the coverage and costs may vary depending on which part of Medicare you have and where you get the drug.

Prolia can be an expensive drug, even with Medicare coverage, but there are some ways to save money on it, such as comparing different Medicare plans, asking for lower-cost alternatives, or applying for financial assistance programs.

If you have any questions or concerns about Prolia coverage and pricing, you should talk to your doctor, pharmacist, or Medicare plan.

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