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does Medicare cover Prolia

Does Medicare Cover Prolia?

Osteoporosis is known as a silent disease because it does not show any symptoms.  

Most of the time, you will only know you have it after you get a broken bone. Most often these fractures occur at the hip, wrist, spine or shoulder.  

Unfortunately, there is not cure for osteoporosis yet. However, there are several treatments that can help delay your bones from deteriorating.  

One of those treatments is an injectable medication called Prolia.  

For those over 65 who want to give this treatment a try, a common question is, “Does Medicare cover Prolia (Denosumab)?” In this article, we answer this question in clear, plain English. You will also find the average costs of Prolia and other helpful info. 

Does Medicare Cover Prolia? 

The short answer is yes; Medicare will cover the cost of Prolia. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your Prolia. Below we look at what these are so you know what to expect. 

Original Medicare (Medicare Part A and Part B) provides coverage for Prolia.  

Coverage for Prolia is usually falls under Medicare Part B. However, for Medicare Part B to provide coverage for your Prolia, there are certain requirements that you must meet. These requirements consist of:  

  • 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 you get Medicare Part B’s approval, they will cover 80 percent of the costs of Prolia.  

Medicare Advantage (Medicare Part C) also provides coverage for Prolia. It covers everything Original Medicare covers as well as some additional benefits. However, exactly what it covers and how much the out-of-pocket costs are will vary depending on the specifics of your plan. 

Part D Coverage 

Aside from Medicare Part B and Part C, most Medicare Part D plans provide coverage for Prolia. Medicare Part D covers 95 percent of the costs of Prolia. It covers 50 percent for those who do not need prior authorization.  

Because coverage for Prolia varies from plan to plan it is best that you discuss the details with your plan and your healthcare provider.  

How Much Does Prolia Cost? 

On average, Prolia costs around $1,280 per treatment. The treatment is usually given every six months.  

What Is Prolia (Denosumab)? 

Prolia, which also goes by the generic name Denosumab, is a prescription medicine that treats osteoporosis. Usually, it is for women after menopause who are at a high risk of having a bone fractured.  

It is also given to those who can’t use other osteoporosis meds. Prolia may also be helpful for those who have tried other osteoporosis medications, but they have had no effect.  

Men can also use this treatment. It can be helpful for men who have osteoporosis and are at high risks of having fractures due to bone loss. It helps them by increasing bone mass. 

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 Green Light Laser Therapy?

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