What Medicare Covers for Prolia

Medicare Part B covers Prolia (denosumab) if your doctor prescribes it to treat osteoporosis or bone loss related to cancer treatment. The drug is administered as an injection in a doctor's office or infusion center, which is why Part B — not Part D — pays for it. You pay 20% of the Medicare-approved amount after you meet your Part B deductible; Medicare pays the other 80%.

Prolia is not covered under Part D (prescription drug plans) because it is not a self-administered oral medication. If your doctor gives you the injection during an office visit, that visit and the drug are both billed under Part B. The coverage applies whether you have Original Medicare or a Medicare Advantage plan, though Advantage plans may have different cost-sharing rules.

Your specific out-of-pocket cost depends on whether you have already met your Part B deductible for the year and whether your plan includes additional coverage. Some Medigap plans cover the 20% coinsurance, which would lower your cost to zero. If you have a Medicare Advantage plan, check your plan documents or call the plan to learn your exact copay or coinsurance amount.

Key Takeaways

  • Prolia is covered under Medicare Part B when prescribed for osteoporosis or cancer-related bone loss, and you pay 20% coinsurance after meeting your deductible.
  • The drug must be injected by a healthcare provider in an office or clinic setting to may have access to for Part B coverage.
  • Medicare Advantage plans cover Prolia but may charge different copays or coinsurance amounts than Original Medicare.
  • If you have a Medigap plan, check whether it covers Part B coinsurance, which could reduce your out-of-pocket cost to nothing.

How to Confirm Coverage Before Your Appointment

Call Medicare directly at 1-800-MEDICARE before your first Prolia injection to confirm coverage under your specific plan. Have your Medicare card ready and tell them the drug name and that it will be injected in your doctor's office. They will tell you whether your plan covers it and what your deductible status is.

If you have a Medicare Advantage plan, call the plan's customer service number on the back of your card instead of calling Medicare. Advantage plans have their own coverage rules and may require prior authorization from your doctor before the injection. Ask whether the plan requires you to use an in-network provider for the injection or whether any provider is acceptable.

Your doctor's office can also check coverage for you. Many offices have staff who verify benefits before treatment. This is often faster than calling yourself, and the office can tell you when ready whether prior authorization is needed.

Prior Authorization and What It Means

Some Medicare Advantage plans require prior authorization before covering Prolia. This means your doctor must submit paperwork to the plan and receive written approval before you receive the injection. The plan reviews whether the drug is medically necessary based on your diagnosis and medical history.

Prior authorization typically takes three to five business days. Your doctor's office usually handles the request at no cost to you. If the plan denies the request, your doctor can appeal or discuss alternative treatments with you. Original Medicare does not require prior authorization for Prolia.

Ask your doctor's office whether your plan requires prior authorization and, if so, when they will submit the request. Do not schedule your injection until the office confirms that authorization has been approved.

What Happens if You Have Not Met Your Deductible

If you have Original Medicare and have not yet met your $240 Part B deductible for 2024, you will pay the full cost of Prolia until the deductible is satisfied. Once you meet the deductible, Medicare pays 80% and you pay 20% coinsurance for the rest of the year.

The deductible resets on January 1 each year. If you are scheduled for a Prolia injection late in the year and have already met your deductible, you will only owe the 20% coinsurance. If you are scheduled early in the year and have not met it, ask your doctor whether the injection can wait until after you have met the deductible, or budget for the full cost upfront.

Medicare Advantage plans have their own deductibles, which may be different from Original Medicare. Some Advantage plans have no deductible for certain drugs or services. Check your plan documents or call the plan to learn your deductible amount and whether you have met it.

Using a Medigap Plan to Lower Your Cost

If you have Original Medicare and a Medigap plan, your Medigap policy may cover the 20% coinsurance you would otherwise owe for Prolia. Most Medigap plans (Plans C, D, F, G, M, and N) cover Part B coinsurance, which means you would pay nothing out of pocket for the drug after meeting your Part B deductible.

Check your Medigap policy documents or call your Medigap insurer to confirm that coinsurance coverage is included in your plan. If you do not have a Medigap plan and are considering one, Prolia coverage is one factor to weigh when comparing plans. You can change Medigap plans during the annual open enrollment period or during certain may have access to life events.

Medigap plans do not work with Medicare Advantage plans. If you have an Advantage plan, you cannot also have Medigap, so this option does not explore to you.

What to Do if Your Plan Denies Coverage

If your plan denies coverage for Prolia, your doctor can file an appeal on your behalf. The appeal process varies by plan type. For Original Medicare, you can request a redetermination from Medicare. For Medicare Advantage, you request an appeal through the plan itself.

Your doctor should include medical records showing your osteoporosis diagnosis, bone density test results, and documentation that other treatments have failed or are not appropriate for you. This information helps the plan or Medicare understand why Prolia is medically necessary in your case.

The appeal process typically takes 30 days. While the appeal is pending, ask your doctor whether you can delay the injection or whether there is an alternative treatment covered by your plan. Do not pay out of pocket for Prolia while an appeal is in progress unless you are certain you will not be reimbursed.

Frequently Asked Questions

Does Medicare cover Prolia for prevention of osteoporosis, or only for treatment?

Medicare covers Prolia for treatment of osteoporosis in people who have been diagnosed with the condition, typically confirmed by a bone density test. Coverage for prevention in people without a diagnosis is less common and depends on your specific plan and doctor's recommendation. Ask your doctor whether your diagnosis qualifies you for coverage.

How often does Medicare cover Prolia injections?

Prolia is typically injected once every six months. Medicare covers each injection as long as your doctor prescribes it and your plan continues to cover the drug. If you stop treatment, you can restart it later if medically necessary, and Medicare will cover it again.

Can I get Prolia at a pharmacy instead of a doctor's office?

No. Prolia must be injected by a healthcare provider in a medical setting. It is not available as a self-injected medication at home or through a retail pharmacy. This is why it is covered under Part B rather than Part D.

What if I have both Original Medicare and a Medicare Advantage plan?

You cannot have both at the same time. You must choose one or the other. If you currently have both, contact Medicare to drop one of them. Having both plans can create billing confusion and is not permitted.

Will my copay change if I switch from Original Medicare to a Medicare Advantage plan?

Yes, it likely will. Original Medicare charges 20% coinsurance after your deductible. Medicare Advantage plans set their own copays and coinsurance amounts, which vary by plan. Some Advantage plans may charge a flat copay for Prolia, while others charge coinsurance. Compare the Prolia costs across plans before switching.