Medicare Part D covers Prolia, but your out-of-pocket cost depends on your plan and which coverage stage you're in

Prolia is a prescription injection used to treat osteoporosis in people with bones that break easily. Medicare Part D (prescription drug coverage) covers it at most plans, but you will pay a copay or coinsurance — the exact amount varies by which plan you chose and whether you've hit your deductible or entered the coverage gap.

The drug itself is expensive (the list price is several hundred dollars per injection), so your actual cost depends heavily on your plan's formulary (the list of drugs it covers) and tier placement. Some plans place Prolia on a higher tier, meaning you pay more. Others negotiate lower prices. You need to check your specific plan's details, not just assume it's covered.

Prolia is given as a shot under the skin every six months, usually in a doctor's office. If your doctor's office administers it there, that's a separate charge (covered under Part B as an injection service), but the drug itself comes through Part D.

Key Takeaways

  • Prolia is covered by Medicare Part D at most plans, but the amount you pay out of pocket depends on your plan's formulary tier and your current coverage stage.
  • You should check your plan's formulary or call the plan directly to confirm Prolia is covered and what your copay or coinsurance will be before your first dose.
  • The injection itself (the administration) is covered under Part B when given in a doctor's office, but the drug cost comes through Part D.
  • If your plan doesn't cover Prolia or places it on a high tier, you may be able to switch plans during the annual enrollment period or ask your doctor about lower-cost alternatives.

How to find out what you'll pay for Prolia

The fastest way is to log into your plan's website and search the formulary for "Prolia" or "denosumab" (the generic name). The formulary will show you which tier it's on and what your copay or coinsurance is. If you don't have online access, call the customer service number on the back of your Medicare card.

When you call or search, have your plan name and member ID ready. Ask specifically: "Is Prolia on the formulary?" and "What is my copay or coinsurance for this drug?" Some plans also require prior authorization, meaning your doctor has to get approval from the plan before you can fill the prescription. Ask about that too.

If Prolia is not on your plan's formulary, ask the representative whether there are similar osteoporosis drugs that are covered. Your doctor may be able to prescribe one of those instead, or you can ask about switching to a different Part D plan during the annual enrollment period (October 15 to December 7 each year).

What happens if Prolia is on a high tier or not covered

If your plan places Prolia on tier 3 or 4 (the highest tiers), your copay could be $75 to $150 or more per injection. If it's not covered at all, you have a few options.

First, ask your doctor whether a different osteoporosis drug might work for you — some alternatives like alendronate (Fosamax) are older and cheaper, and many plans cover them at lower tiers. Second, you can switch to a different Part D plan during the annual enrollment period. Use the Medicare Plan Finder tool on Medicare.gov to compare plans and see which ones cover Prolia at the lowest cost in your area.

Third, check whether Prolia's manufacturer (Amgen) offers a copay information program. Many drug makers help patients pay their share if the copay is high. Your doctor's office or the pharmacy can help you look into this.

Coverage stages and how they affect your Prolia cost

Part D has four coverage stages: the deductible, initial coverage, the coverage gap, and catastrophic coverage. Where you are in the year affects what you pay.

In the deductible stage, you pay the full price of the drug until you've spent the amount your plan sets as the deductible (usually $505 to $550 in 2024, though this changes yearly). Once you hit the deductible, you move to initial coverage, where you pay a copay or coinsurance and the plan pays the rest.

If your drug costs are high, you may enter the coverage gap (sometimes called the "donut hole"). In this stage, you pay a larger share of the drug cost — currently 25% of the price. Once your out-of-pocket spending reaches a certain limit (around $7,050 in 2024), you move to catastrophic coverage, where you pay only a small copay and the plan covers the rest.

Because Prolia is given only twice a year, you may not hit the coverage gap at all. But if you take other expensive drugs, you could. Ask your plan representative to estimate where you'll be in the coverage stages by the time you need your next Prolia injection.

What to ask your doctor before starting Prolia

Before your first injection, tell your doctor which Medicare plan you have and ask them to check whether Prolia is covered. If it's not, ask whether an alternative osteoporosis drug would work for you. Your doctor should also check your kidney function before starting Prolia, because the drug is not recommended for people with severe kidney disease.

Ask your doctor's office whether they will administer the injection in the office (covered under Part B) or whether you'll need to go to a pharmacy. If it's in the office, ask what the administration fee will be — this is separate from the drug cost and is covered under Part B, not Part D.

Also ask your doctor about side effects to watch for, especially jaw problems and unusual fractures, which are rare but serious. Know when to call the office if something doesn't feel right.

When to contact Medicare or your plan

Call your Part D plan if Prolia is denied when you try to fill it, or if the copay is higher than you expected. The plan can explain why and tell you whether you can appeal the decision or request an exception.

Contact Medicare directly (1-800-MEDICARE) if you believe your plan is not following Medicare rules or if you need help understanding your coverage. You can also ask about switching plans if your current one doesn't cover Prolia well.

If you can't afford the copay even after checking information programs, tell your doctor. They may have samples, know of other resources, or be able to prescribe a covered alternative.

Frequently Asked Questions

Does Medicare Part B cover Prolia instead of Part D?

No. Part D covers the drug itself. Part B covers only the administration (the injection service) if it's given in a doctor's office. The drug cost always goes through Part D, so you need Part D coverage to use Prolia.

Can I use a GoodRx coupon or discount card instead of my Medicare plan?

You should not use a discount card or coupon if you have Medicare Part D. Using one instead of your plan can affect your coverage and may cause problems with your plan's tracking of your costs. Always use your Medicare plan for prescription drugs.

What if I'm in the coverage gap when I need my Prolia injection?

You'll pay 25% of the drug cost while in the gap. Because Prolia is expensive, this could be a significant amount. Ask your plan to estimate your costs for the year so you know whether you'll hit the gap and when.

Is there a lower-cost version of Prolia I can ask for?

Prolia is a brand-name biologic drug, and there is no generic version yet. However, biosimilars (drugs very similar to biologics) may become available in the future. For now, ask your doctor about other osteoporosis drugs that might be covered at a lower tier on your plan.

Can I switch Medicare plans if my current one doesn't cover Prolia well?

Yes, during the annual enrollment period (October 15 to December 7), you can switch to a different Part D plan. Use the Medicare Plan Finder tool on Medicare.gov to compare plans in your area and see which ones cover Prolia at the lowest cost.