Simply put: Yes, as long as your doctor has deemed it medically necessary and you meet Medicare’s other requirements, Part B helps pay for Prolia shots.
Prolia is the brand name of a biologic medication called denosumab. It is used to treat or prevent bone loss to reduce risk of osteoporosis and bone fractures.
Typically, Prolia is reserved for patients who have not responded to other treatment methods and those with severe osteoporosis. This is due, in part, to the risk of serious side effects that accompany most biologic drugs.
When does Medicare cover Prolia injections?
If you meet the following criteria, Original Medicare (Parts A and B) helps pay for the medication and visits from a home health nurse to provide the injection:
- You qualify for Part B and for home health services
- Your doctor certifies you cannot give yourself the injection and your caregivers/family members are unwilling and unable to give you the injection
- You are a woman
- You have a bone fracture that your doctor has certified is related to postmenopausal osteoporosis
What is Prolia?
Prolia is an injectable medication that helps people who have been with osteoporosis. It has been approved by the FDA to reduce bone loss and fracture risk.
Your body has cells called osteoclasts, which keep your skeleton strong by breaking down old bone to build up new bone in its place. As we age, the process of building bone slows down, but the osteoclasts continue to work just as fast, which leads to a loss in bone density. Prolia slows down this bone loss by disrupting the activation of these osteoclast cells.
Although most prescription drugs are not covered by Original Medicare, Part B will help pay for medications that must be administered by a healthcare professional. In this case, Part B will cover Prolia injections if you meet the Medicare requirements in the previous section.
If you do not meet the above criteria listed for Prolia, it may still be covered by your Part D (prescription drug) plan. According to GoodRX, 97% of Part D plans cover Prolia, though you'll likely have a copay.
Remember that, because Prolia is a name brand drug and does not have a generic equivalent, it will likely be in a higher tier on your plan's formulary. And the higher the tier, the higher your share of the cost.
How much does Prolia cost?
Cost depends on how you qualify for Prolia coverage. If you get your coverage from Medicare Part B, your plan usually covers 80% of the injection, leaving you owing the remaining 20% out-of-pocket. This amounts to about $250 per injection, with most people getting one injection every six months. Typically, you must meet your Part B deductible before Medicare covers the medication.
If you go through Medicare Part D, you generally need to pay the full price of the drug until you meet your Part D deductible. After this, your plan covers at least some of the medication, while you have a copay.
When the amount you've spent on prescription medications reaches the threshold for your coverage gap, you are responsible for 25% of the cost of Prolia. In 2023, this amounts to $4,600. Once you've reached the upper limit of your coverage gap ($7,400 in 2023), your plan will usually cover most of the cost, with you only paying a copay.
Related reading:Medicare Donut Hole: What You Need to Know
Are there alternatives to Prolia?
The generic name for Prolia is denosumab and, while there have been no FDA approvals of a generic form of the medication, there is another brand name version called Xgeva.
Xgeva may be covered by Medicare Part D, but the cost for injections could be more or less than they are for Prolia, depending on where it falls in your formulary.
Your doctor may prescribe other bone-building drugs instead of Prolia, such as abaloparatide and teriparatide. You could also be prescribed hormone therapy, or bisphosphonates like ibandronate and zoledronic acid.
Does Medicare Advantage cover Prolia?
If you would be covered for Prolia injections under Medicare Part B, a Medicare Advantage plan will cover it in the same way.
Also known as Medicare Part C, Medicare Advantage is just a way to combine your Original Medicare coverage into a single plan. As long as you qualify for it under Original Medicare, an Advantage plan must cover the same conditions.
A Medicare Advantage plan with prescription drug coverage will likely cover the injections in the same way a standalone Part D plan would, depending on your plan's drug formulary.
It is important to note that, outside of being federally required to hold to the same requirements of coverage of Original Medicare, Medicare Advantage plans are offered by private insurers, so cost and coverage options vary. If you plan to get Prolia through a Medicare Advantage plan with drug coverage, you need to make sure that the medication is covered by the plan you choose.
If you are ready to start comparing Medicare Advantage plans, the quickest and easiest way is with our Find a Plan tool. Simply enter your zip code and medications, and you'll be sorting through plans in no time.
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