Prolia® Medicare Coverage

Prolia®
Chemical name: Denosumab

Typical dosage: 60mg/ml

Typical type: Injection1

Prolia® is typically used to help treat osteoporosis in men and in women who are at increased risk for weakened bones after menopause. It can also be used to help treat bone loss in cancer patients who are receiving treatment for prostate cancer (men) or breast cancer (women). Prolia is available as an injection.

Prolia is an injection administered by or under the supervision of your doctor. 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.

Some less common side effects can include back pain, skin rashes, swelling, muscle or bone pain, frequent urges to urinate, heartburn, difficulty sleeping and others.

Does Medicare 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

  • 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.

Find Medicare Advantage plans with drug coverage

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Or call TTY Users: 711 24/7 to speak with a licensed insurance agent.

Average costs for Prolia with Medicare drug coverage1

Your copay and deductible costs for any prescription drug can vary depending on what coverage stage you’re in.

Deductible stage Typical copay stage
Your deductible is the amount of money you must spend on covered drugs before your Medicare drug coverage starts paying its share of costs.

In the deductible stage, you’re responsible for the full cost of your prescription drugs.

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.

During this phase (the typical copay stage), you pay a copayment (flat fee) or coinsurance (percentage) for your covered medications.
$95 – $1,364 $70 – $1,364

Additional information

Prolia should be given by a licensed healthcare provider in a healthcare facility.

Do not take Prolia if you are pregnant or planning on becoming pregnant. 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.

 

 

This article is for informational purposes only. It is not healthcare advice, treatment, or diagnosis. It is not an endorsement of or recommendation for this medication. Speak to your doctor or healthcare provider about your specific healthcare needs, including your prescription medications. Only take medication as directed by your doctor.

Coverage and costs of prescription medications will vary by Medicare plan. Not all plans are available in all areas.

 

Written by Hayden Gharibyar, Pharm.D.