Medicare Part D covers Prolia, but only if your plan includes it and you meet the plan's cost-sharing rules
Prolia is a prescription medication for osteoporosis that you inject yourself twice a year. Medicare Part D (prescription drug coverage) does cover Prolia, but whether you pay nothing, a copay, or coinsurance depends on which Part D plan you have and where Prolia sits on that plan's formulary — the list of drugs the plan covers.
Not every Part D plan covers Prolia the same way. Some plans may require you to try a different osteoporosis medication first, or they may place Prolia in a higher cost tier that means you pay more out of pocket. Your specific costs also depend on whether you have already met your deductible and how much you have spent on other drugs that year.
The best way to find out what you will pay is to check your plan's formulary directly or call the plan's customer service number on the back of your Medicare card.
Key Takeaways
- Prolia is covered under Medicare Part D (prescription drug coverage), not Part A or Part B.
- Your out-of-pocket cost depends on your specific Part D plan's formulary and cost tier, which vary widely between plans.
- Some plans may require prior authorization or step therapy (trying another drug first) before covering Prolia.
- You can check your plan's coverage and your estimated cost by reviewing your plan's formulary or calling your plan directly.
How Medicare Part D covers Prolia
Part D plans organize drugs into tiers, usually four or five levels. Tier 1 drugs (generics) cost the least. Tier 2 drugs (preferred brand-name) cost more. Tier 3 and Tier 4 drugs cost even more. Prolia is a brand-name biologic medication, so it typically lands on Tier 3 or Tier 4, meaning you will likely pay more than you would for a generic osteoporosis pill.
Your actual cost at the pharmacy depends on what stage of the year you are in. Early in the year, you may owe your deductible first (usually $505 to $550 in 2024, though this changes yearly). After you meet the deductible, you typically pay a copay or coinsurance — a percentage of the drug's cost. Once you and your plan have spent a certain amount together (the coverage gap threshold), your costs change again.
Because Prolia is an injectable medication given only twice a year, you will not fill it as often as a daily pill. This means your annual out-of-pocket cost for Prolia alone may be lower than for a daily medication, even if each dose costs more.
Prior authorization and step therapy requirements
Some Part D plans require prior authorization before they will cover Prolia. This means your doctor must contact the plan and explain why Prolia is medically necessary for you. The plan then approves or denies the request. This process usually takes a few business days but can delay your first dose.
Other plans use step therapy, which means you must try a different osteoporosis medication first — often a generic bisphosphonate pill like alendronate — before the plan will cover Prolia. If that first medication does not work for you or causes side effects, you can then request coverage for Prolia. Your doctor can help you appeal if step therapy is blocking access to the medication your doctor believes you need.
Check your plan's formulary or call the plan before your doctor's appointment to find out whether prior authorization or step therapy applies to you. This way, your doctor can start the process early if needed.
What to do if your plan does not cover Prolia
If your current Part D plan does not cover Prolia, or if the cost tier is too high, you have options. During the annual enrollment period (October 15 to December 7 each year), you can switch to a different Part D plan that does cover Prolia at a lower cost. You can compare plans on Medicare.gov using the Plan Finder tool, which shows you the estimated cost of Prolia under each plan in your area.
If you need Prolia before the next enrollment period, talk to your doctor about whether a generic bisphosphonate or other osteoporosis medication might work for you in the meantime. You can also ask your doctor's office to request an exception from your plan — a formal appeal asking the plan to cover Prolia even though it is not on the formulary or is in a higher tier. Plans sometimes grant exceptions if your doctor documents that you cannot tolerate other medications.
Amgen, the manufacturer of Prolia, also offers a patient information program that may reduce your cost if you meet income requirements. Ask your doctor's office or pharmacist whether you might be may be able to access.
Comparing Prolia to other osteoporosis treatments
Prolia is one of several medications used to treat osteoporosis. Generic bisphosphonates like alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) are often cheaper because they are generic pills. However, they require daily or weekly dosing and can cause stomach upset if not taken correctly. Prolia requires only two injections per year, which some people find easier to remember and tolerate.
Other options include Forteo (teriparatide), which is also an injectable but works differently and may cost more, and Reclast (zoledronic acid), an IV infusion given once a year. Your doctor will recommend the medication that best fits your bone density, medical history, and ability to tolerate side effects. Cost should be part of that conversation, but it should not be the only factor.
If cost is a barrier, tell your doctor. They may be able to prescribe a medication that is covered at a lower tier on your plan, or they can help you appeal your plan's decision.
Questions to ask your doctor and Medicare plan
Before you start Prolia, ask your doctor: "Does my Medicare plan cover Prolia, and if so, what will my out-of-pocket cost be?" Ask your doctor's office to check your plan's formulary or to call your plan directly — they do this regularly and can get a quick answer.
Ask your plan: "Is Prolia on my formulary? What tier is it on? Do I need prior authorization or step therapy?" You can find this information in your plan's formulary (usually available on the plan's website) or by calling the customer service number on your Medicare card.
If your plan requires step therapy, ask your doctor: "If the first medication does not work, will you help me appeal for Prolia coverage?" Knowing this in advance prevents delays later.
When to contact your plan or doctor
Contact your plan when ready if your pharmacy tells you that Prolia is not covered or that your cost is higher than you expected. Do not wait until you are at the pharmacy counter — call ahead so your doctor and plan can resolve it before your injection appointment.
Contact your doctor if you have taken Prolia and experience severe side effects, or if you have questions about whether Prolia is still the right medication for you. Osteoporosis treatment is long-term, and your needs may change.
If you are turning 65 and will be on Medicare for the first time, enroll in Part D during your initial enrollment period (the seven months around your 65th birthday). If you delay, you may face a permanent penalty on your premiums.
Frequently Asked Questions
Does Medicare Part A or Part B cover Prolia?
No. Part A covers hospital stays and Part B covers doctor visits and some outpatient services. Prolia is a prescription medication, so it is covered only under Part D. If you do not have Part D, you will pay the full cost of Prolia out of pocket unless you have other prescription coverage.
What if I cannot afford my copay for Prolia?
Ask your pharmacist or doctor's office about patient information programs. Amgen offers a copay card that may reduce your out-of-pocket cost to as little as $0 per injection, depending on your income and insurance. Your doctor's office can help you explore.
Can I switch Medicare plans to get better coverage of Prolia?
Yes, during the annual enrollment period (October 15 to December 7). Use Medicare.gov's Plan Finder to compare Part D plans in your area and see the estimated cost of Prolia under each one. You can also switch plans if you move or if your plan stops covering Prolia.
What happens if my plan stops covering Prolia?
If your plan removes Prolia from its formulary or moves it to a higher cost tier mid-year, you can request a coverage exception from your plan, or you can switch to a different Part D plan during the annual enrollment period. Your doctor can help you request an exception by documenting medical necessity.
Is there a generic version of Prolia?
No. Prolia is a biologic medication, and there is no generic version. However, biosimilars (medications very similar to Prolia) may become available in the future and could cost less. Ask your doctor whether a biosimilar is an option for you once one is approved and covered by your plan.