Does Medicare Cover Prolia?
Yes, Medicare does cover Prolia if the treatment is medically necessary and you meet all the following conditions:
- You are a woman.
- You have Medicare Part B.
- You have a bone fracture that a doctor can certify as related to postmenopausal osteoporosis.
The type of Medicare coverage that pays for your Prolia treatment will depend on where and how you receive your care. For injections from a licensed home nurse to qualify for Medicare coverage, you will need additional verification from a doctor stating that you and your caregivers cannot competently administer the drug and that you meet Medicare’s “home health services” requirements.
Table of Contents
What Is Osteoperosis and Prolia?
Osteoporosis is a medical condition in which the bones gradually lose tissue and become brittle, typically due to hormonal changes or a lack of certain nutrients. Though anybody can contract osteoporosis, it affects women over 50 four times as often as men of the same age, primarily due to menopause and lower lifetime bone densities.
While Medicare will only approve Prolia for female members, anybody can use it as an effective way to manage osteoporosis. Unlike most other prescription drugs, you, your caregivers, or your medical team must administer Prolia through a bodily injection. These shots allow the active mechanism in Prolia, denosumab, to decelerate the development of bone-removing cells in your body for up to six months.
How Does Medicare Coverage of Prolia Work?
Medicare Part A, Part B, or Part D may all cover Prolia treatment, depending on where and how you receive your injections.
Eligibility Criteria for Prolia
To qualify for Prolia under Medicare, a doctor must prescribe the drug as medically necessary to treat osteoporosis in female patients. These women must first experience a bone fracture directly connectable to the disease before a doctor can justify denosumab injections as a medical necessity.
Medicare Part B will cover Prolia shots biannually. However, if you need a licensed home nurse to perform the service, Medicare Part A could cover their fee. To qualify for Part A home health services, a doctor must certify you as homebound and have you under a disciplined plan of care. Depending on their policy’s drug formulary, some members can also purchase Prolia through Medicare Part D.
How Often Can You Access Prolia?
Eligible osteoporosis patients can only receive Medicare covered Prolia shots once every six months. Denosumab will remain in their system throughout this period, actively fighting bone-reducing cells in their bodies. Once the previous injection wears off, patients will require a new dosage to continue medically necessary treatment.
Due to the drug’s longevity, additional injections within the prescribed six months window do not qualify as medically necessary. Furthermore, denosumab can cause aggravated side effects in high doses, the least of which include severe jaw issues and broken thigh bones. Instead of expediting their dosage rate, doctors will instruct patients to underscore pharmaceutical treatment with daily vitamin D and calcium supplements.
How Does Medigap Cover Prolia?
Original Medicare members can purchase Medicare Supplement, or Medigap, to help pay for traditionally out-of-pocket expenses like deductibles, copayments, and coinsurance. With Prolia treatment, what your Medigap plan covers depends on how you receive your care.
For example, if you administered the injections yourself, Medigap could cover your $226 Part B deductible and the 20% coinsurance due for the drug. Medigap could also absorb some of your Part A copayments and deductible charges if a licensed home care nurse performed the service.
How Does Medicare Advantage Cover Prolia?
Medicare Advantage plans must legally offer all the same benefits as Original Medicare and occasionally extend coverage to include dental and vision care. Because Original Medicare will pay for Prolia, Medicare Advantage must also guarantee coverage. As always, patients must first receive a doctor’s prescription verifying Prolia as medically necessary treatment.
Most Medicare Advantage plans include prescription drug coverage, further expanding Prolia payment options. However, because private companies oversee Medicare Advantage policies and impose independent rules and price structures, patient out-of-pocket costs will vary from plan to plan. Medicare Advantage providers can also change their coverage benefits yearly, so ensure you stay up-to-date on your policy details before purchasing each Prolia shot.
How Much Does Prolia Cost?
As of January 4, 2023, Prolia costs $1,564 per dose before insurance coverage. After meeting their annual Part B deductible, Original Medicare members would only have to pay 20% of the Medicare-approved amount for each injection. Medicare would also fully cover eligible patients’ home nurse fees if a doctor certifies they cannot administer the injection independently.
Medigap members will see additional price breaks relative to their policy details. Likewise, Medicare Advantage beneficiaries could pay less out-of-pocket with the right plan. Final costs can also vary depending on whether the presiding doctor orders Prolia from a distributor or a pharmacy.
Cost of Treatment
Cost of Treatment with Original Medicare
$539 ($313 coinsurance + $226 deductible)
Cost of Treatment with Medigap
$0-$270, depending on your policy type
Cost of Treatment with Medicare Advantage
Varies from plan to plan.
How To Get Access to Prolia With Medicare
Receiving Prolia treatment through Medicare should prove relatively simple by following the steps below:
- Review your coverage details: Contact your Medicare agent to verify how Original Medicare will cover Prolia treatment and to what extent. If you have Medicare Part D, Medicare Advantage, or Medigap, call the private insurers managing those policies.
- Determine your eligibility: Medicare Part B will only cover Prolia for women with recent osteoporosis-related bone fractures. Homebound patients must meet Medicare’s home health services criteria to qualify for injections from a licensed nurse.
- Schedule a doctor’s appointment to secure a prescription: Once your doctor identifies an osteoporosis-related fracture, they can prescribe Prolia as medically necessary in treating your condition, officially qualifying it for Medicare coverage.
- Receive care and pay your share of the costs: Self-inject your biannual denosumab dosage or have your doctor, a confident family member, or a licensed home nurse administer the shot. Final out-of-pocket costs will depend on how you receive care, the extensiveness of your Medicare package, and how your doctor orders the drug.
Should You Access Prolia With Medicare?
Yes, if you are a woman with Original Medicare Part B suffering from osteoporosis, you should seek Prolia treatment. Once a doctor can link a recent bone fracture to your degenerative disorder, you become eligible for Medicare-covered Prolia injections. Members only pay a 20% coinsurance for each service after meeting their deductible.
Significant hormonal shifts like menopause can accelerate the growth of bone-removing cells in the body, heightening the risk of osteoporosis in women over 50. Every biannual Prolia injection temporarily stunts this growth and allows bone matter to regenerate, reducing the risk of breaks or fractures. This knowledge helps patients confidently fulfill normal daily activities without fear of injury.
- Long lasting
- Reduces bone fractures
- Cost covered by Medicare up to 80%
- Can you help one qualify for in home nursing care
- Not available without prior injury
- Can be expensive even with coverage
- Side effects
- Only available to women through Medicare
Medicare-covered Prolia treatments offer many benefits, including:
- Each Prolia dose remains active in the body for six months, meaning patients only need to undergo injections twice annually.
- Prolia can significantly reduce the risk of bone fractures in osteoporosis patients, allowing them to move about more confidently.
- Medicare Part B will cover 80% of Medicare-approved costs for Prolia.
- Members with Medicare Advantage, Medicare Part D, or Medigap may pay even less out-of-pocket for treatment.
- Some homebound patients will also qualify for free home nursing care, given they cannot independently perform their injections.
However, getting Prolia covered by Medicare also presents a few key downsides:
- Known osteoporosis patients will not qualify for Medicare-covered Prolia treatments until the disease causes a bone fracture.
- Because of the high price point of each Prolia injection, a 20% coinsurance plus deductible fees still amounts to hundreds of dollars out-of-pocket.
- As with all medications, Prolia users can experience minor and significant side effects. These can run the gamut from itchy skin to back pain, nausea, severe jaw bone issues, and unusual thigh bone fractures.
- Though men and women can both develop osteoporosis, Medicare will only cover medically necessary Prolia treatment for women.
Putting It All Together
As we age, our bone cells start dying faster than they can regenerate, often leading to osteoporosis. In light of significant hormonal changes from menopause that directly affect
bone growth, Medicare only covers Prolia injections for women. To qualify for treatment, a doctor must prescribe Prolia as medically necessary in managing the disease and preventing repeat bone fractures.
Knowing you have the proper medication and care to keep your osteoporosis at bay can help you live a happier, more active, and more comfortable life. Contact your Medicare agent to learn how you might qualify for Medicare-approved Prolia injections and what percentage of costs it will cover.