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Osteoporosis is a condition that is most common amongst the elderly population. It is a disease that weakens a person’s bones and makes them brittle.
Although there is no known cure for osteoporosis, it can be treated using an injectable medication known as denosumab injections, or the brand name, Prolia.
If this is a treatment you or a loved one need, then a common question you likely have is “does Medicare cover denosumab injections?”
In this article, we answer that question in clear, plain English. You will also find the average costs of denosumab injections if you don’t have insurance coverage and have to pay for it out of pocket.
Does Medicare Cover Denosumab Injections?
The short answer is yes. Medicare will cover the cost of denosumab injections. But this is not true 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your denosumab injections. Let’s take a look at what these conditions are below so you know what to expect.
Original Medicare Coverage
Original Medicare (Medicare Part A and Part B) provides coverage for denosumab injections. You can expect Original Medicare to provide coverage for your denosumab injections if it is considered medically necessary. Your healthcare provider must first order the operation for Original Medicare to provide coverage.
Medicare Part B Coverage
Coverage for the administration of denosumab injections is provided by Medicare Part B. However, there are conditions that you have to meet in order to get coverage for denosumab injections.
Medicare Part B will provide coverage for denosumab medications for the following reasons:
- If you have a bone fracture due to post-menopausal osteoporosis.
- If you or any of your family members are unwilling or unable to administer the injection and your healthcare provider can provide evidence for this.
Once approved, Medicare Part B covers 80 percent of the costs of denosumab injections. You will pay for the remaining 20 percent.
Part C Coverage for Denosumab
Medicare Advantage plans (Medicare Part C) also provide coverage for denosumab injections. These plans must cover everything Original Medicare covers, though they will offer some additional benefits too. However, Part C plan differ in what additional treatments, services, etc. they offer plan members as well as what the out-of-pocket costs are.
Medicare Part C plans that include prescription drug plans will also provide coverage for medications your healthcare provider will prescribe to you.
Part D Coverage for Denosumab
Medicare Part D plans also provide coverage for denosumab injections. Part D is a prescription drug plan, and just like Part C, Part D plans are provided by private insurance companies. Ninety-eight percent (98%) of both Part C and Part D plans provide coverage for the medication denosumab injections.
Limitations on Denosumab Coverage
Most Medicare plans restrict the amount of purchase for denosumab injections per one time. If you need to purchase more Denosumab injections at one time, Medicare may not cover it.
You have a couple options here: you can wait until your next period to refill, or contact your plan provider and ask for an exception.
Denosumab injections are listed as a Tier 4 drug in the Medicare drug formulary. Tier 4 medications are more expensive than Tier 1, 2, and 3 medications.
Most plans may require you to have authorization before they provide coverage for this medication. You must use this medication exclusively for necessary reasons.
How Much Does Prolia (Denosumab) Cost?
On average, a single syringe (1ml) of 60 mg/ml Prolia (Denosumab) costs $2,000. This may depend on the pharmacy.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series including: Does Medicare cover walk in clinics?