What Medicare covers for Prolia

Medicare Part B covers Prolia (denosumab) if your doctor prescribes it for osteoporosis and you meet certain conditions. Prolia is a bone-strengthening injection given twice a year. Medicare pays for the drug itself, but you pay a share of the cost through your Part B deductible and coinsurance.

Your out-of-pocket cost depends on whether you use an in-network provider and which phase of the Part B deductible and coinsurance you are in for that year. If you have a Medigap or Medicare Advantage plan, your costs may be lower because those plans cover some or all of what Medicare does not.

Prolia must be given by a healthcare provider in a medical office or clinic — you cannot give it to yourself at home. The provider bills Medicare directly, and Medicare pays 80% of the approved amount after you have met your Part B deductible. You are responsible for the remaining 20%.

Key Takeaways

  • Medicare Part B covers Prolia injections for osteoporosis if your doctor prescribes it and you meet medical necessity requirements.
  • You pay your Part B deductible plus 20% coinsurance for each Prolia injection, unless a Medigap or Medicare Advantage plan covers the remainder.
  • Prolia must be administered by a healthcare provider in an office or clinic setting, not self-injected at home.
  • Your doctor must document that you have osteoporosis or a condition that puts you at high risk of fracture for Medicare to cover the cost.
  • Some Medicare Advantage plans may require prior authorization before your doctor can prescribe Prolia.

Medical requirements Medicare uses to cover Prolia

Medicare requires your doctor to document that you have osteoporosis or another bone condition that increases fracture risk. This usually means you have had a bone density test (DEXA scan) showing low bone mass, or you have already had a fracture from a fall or minor trauma.

Your doctor must also show that other treatments have not worked or are not suitable for you. Medicare may ask for records showing you tried or could not tolerate oral bisphosphonates (pills like alendronate or risedronate) first, since those are usually the first-line treatment and cost less.

If you have kidney disease, your doctor needs to confirm your kidney function is adequate for Prolia. Medicare will not cover it if your estimated glomerular filtration rate (eGFR) is below 30, because the drug is not considered safe at that level of kidney function.

How much you will pay out of pocket

Your costs break down into two parts: the Part B deductible and coinsurance. In 2024, the Part B deductible is $240 per year. Once you have paid that amount toward Part B services, you then pay 20% of the Medicare-approved amount for each Prolia injection.

The Medicare-approved amount for Prolia varies by location and the specific code your provider uses to bill. You can call your doctor's office or the clinic where you will receive the injection and ask them to tell you the approved amount, then calculate 20% of that number to estimate your share.

If you have already met your Part B deductible earlier in the year for another service, you will pay only the 20% coinsurance for Prolia. If you have not met it yet, your first Prolia injection will count toward the deductible until you reach $240, then you pay 20% of the rest.

Medigap and Medicare Advantage coverage of Prolia

If you have a Medigap plan, the plan covers some or all of your Part B coinsurance depending on which Medigap letter plan you own. Most Medigap plans cover the full 20% coinsurance for Prolia after you meet your Part B deductible. A few plans cover the deductible as well, so you would pay nothing.

Medicare Advantage plans cover Prolia through their Part B benefit, but the amount you pay depends on your specific plan's formulary and cost-sharing rules. Some plans may charge a copay instead of coinsurance, or may require prior authorization from the plan before your doctor prescribes it. Call your plan's member services number to find out your exact cost.

If you are switching from Original Medicare to a Medicare Advantage plan or vice versa, check the new plan's coverage for Prolia before the switch takes effect. Some plans may not cover it, or may cover it only under certain conditions.

Prior authorization and what your doctor needs to do

If you have a Medicare Advantage plan, your doctor may need to request prior authorization before prescribing Prolia. This means the doctor's office contacts your plan to confirm the plan will cover the drug before you receive it. The process usually takes a few business days.

Your doctor will need to submit your bone density test results, any fracture history, and documentation that you have tried or cannot take oral bisphosphonates. Keep copies of these records yourself so you can provide them quickly if your plan requests them.

If your plan denies prior authorization, you have the right to appeal. Your doctor can submit additional information or a letter explaining why Prolia is medically necessary for you. The appeal process takes longer, so ask your doctor's office about the timeline.

Other bone-strengthening drugs Medicare covers

If Prolia is not covered or you cannot afford it, Medicare covers other osteoporosis treatments. Oral bisphosphonates like alendronate (Fosamax) and risedronate (Actonel) are usually covered with a small copay or coinsurance under Part D (prescription drug coverage). These are taken weekly or monthly at home.

Teriparatide (Forteo) is another injectable option Medicare covers under Part B with the same cost-sharing as Prolia. It is given daily by self-injection, so you do not need to go to a clinic. Some people tolerate one drug better than another, so talk to your doctor about which option fits your situation.

Raloxifene (Evista) is an oral medication that works differently from bisphosphonates and may be covered under Part D. Your doctor can help you weigh the pros and cons of each option based on your bone density, fracture risk, kidney function, and ability to tolerate the medication.

What to ask your doctor before starting Prolia

Ask your doctor whether your bone density test results and fracture history meet Medicare's requirements for coverage. If you have not had a recent DEXA scan, ask whether you need one before starting Prolia, because Medicare will want documentation of low bone mass.

Ask whether you need to try an oral bisphosphonate first, or whether your situation qualifies you to start Prolia directly. Ask about side effects and what to watch for, especially jaw problems or unusual fractures, which are rare but serious.

Ask your doctor's office to tell you the Medicare-approved amount for Prolia so you can calculate your 20% coinsurance. If you have a Medicare Advantage plan, ask whether prior authorization is needed and how long it takes. Ask whether the clinic accepts Medicare assignment, which means they accept Medicare's approved amount as full payment for their services.

When to contact Medicare or your plan

Contact Medicare (1-800-MEDICARE) if you have Original Medicare and want to confirm that Prolia is covered under your plan, or if you have questions about your Part B deductible or coinsurance. They can also tell you whether your doctor is enrolled in Medicare.

Contact your Medicare Advantage plan's member services number if you need to know whether prior authorization is required, what your copay or coinsurance will be, or whether Prolia is on your plan's formulary. The number is on your insurance card.

If your claim is denied, you have the right to appeal. Your doctor's office can help you file an appeal and provide the medical records needed to support it. Ask the plan or Medicare how long the appeal process takes so you know when to expect a decision.

Frequently Asked Questions

Can I get Prolia at home, or do I have to go to a clinic?

Prolia must be given by a healthcare provider in a medical office, clinic, or hospital — you cannot self-inject it at home. Medicare covers it only when a licensed provider administers it. If you prefer a self-injected bone drug, ask your doctor about teriparatide (Forteo), which Medicare also covers and you can give yourself daily at home.

What happens if my Medicare Advantage plan denies Prolia?

You can ask your doctor to file an appeal with the plan, providing medical records and a letter explaining why Prolia is necessary for you. If the plan denies the appeal, you can file a grievance with Medicare. Your doctor's office can guide you through the appeal process and timeline.

Will Medicare cover Prolia if I have never taken a bisphosphonate?

Medicare may require documentation that you tried an oral bisphosphonate first or that you cannot take one due to side effects or medical reasons. Ask your doctor whether your situation qualifies you to start Prolia directly, or whether you need to try a pill first. Your doctor can submit medical records to support either path.

Does my Medigap plan cover the Part B deductible for Prolia?

Most Medigap plans cover the 20% coinsurance for Prolia, but only a few cover the Part B deductible. Check your Medigap plan documents or call your plan to find out whether your plan covers the deductible. If it does, you may pay nothing for Prolia after you meet the deductible through other services.

What if I cannot afford the 20% coinsurance for Prolia?

Talk to your doctor about lower-cost alternatives like oral bisphosphonates, which usually have a small copay under Part D. Some pharmaceutical companies offer copay information programs for Prolia if you meet income requirements — ask your doctor's office whether you may have access to. Your local Area Agency on Aging may also know about programs that help with medication costs.