Your Out-of-Pocket Cost for Prolia Depends on Your Medicare Plan and Pharmacy

Prolia (denosumab) is a bone-strengthening injection used to treat osteoporosis. Under Medicare, what you pay depends on whether you have Original Medicare with a Part D prescription plan, a Medicare Advantage plan, or no drug coverage at all. Most people with Part D pay between $0 and $250 per injection after their deductible, but the exact amount varies by plan and pharmacy.

Prolia is given as a shot under the skin every six months, usually at a doctor's office or clinic. Medicare Part B covers the injection itself when a doctor administers it. The drug itself — the medication in the syringe — is covered under Part D (prescription drug coverage) if you have it, or under a Medicare Advantage plan's drug benefit. If you have no drug coverage, you pay the full pharmacy price, which typically runs $1,500 to $2,000 per injection before any discounts.

The cost you see at the pharmacy counter is not the same as what Medicare pays. Medicare negotiates prices with pharmacies, and your share depends on which tier Prolia sits on in your plan's formulary — the list of covered drugs ranked by cost. Most plans place Prolia on Tier 3 or Tier 4, meaning you pay a higher copay than you would for a generic drug.

Key Takeaways

  • With Original Medicare Part D, you typically pay $0 to $250 per Prolia injection after you meet your deductible, depending on your plan's tier and copay structure.
  • Medicare Advantage plans cover Prolia differently — some charge a copay, others use coinsurance (a percentage of the cost), and coverage varies widely by plan.
  • The injection itself (the doctor's administration) is covered under Part B, but the drug cost is covered under Part D or your Advantage plan's drug benefit.
  • If you have no drug coverage, you pay the full pharmacy price of roughly $1,500 to $2,000 per injection, though manufacturer discounts and patient information programs may lower this.
  • Your actual cost changes each year when plans renew, so checking your formulary during open enrollment is the only way to know your real out-of-pocket amount.

How Original Medicare Part D Covers Prolia

If you have Original Medicare (Parts A and B) plus a standalone Part D prescription drug plan, Prolia coverage works in stages. First, you pay your plan's annual deductible — typically $505 to $550 in 2024, though this amount changes yearly. Once you meet the deductible, you move into the copay stage, where you pay a fixed amount per prescription.

Most Part D plans place Prolia on Tier 3 or Tier 4. A Tier 3 copay might be $50 to $100 per injection. A Tier 4 copay might be $100 to $250 per injection. Some plans use coinsurance instead — you pay a percentage of the drug's cost (often 25% to 33%) rather than a flat copay. Since Prolia costs $1,500 to $2,000 at full price, a 25% coinsurance could mean paying $375 to $500 per injection.

After you and your plan together spend $7,050 in 2024 (the exact amount changes yearly), you enter the coverage gap, sometimes called the "donut hole." In the gap, you pay 25% of the drug's cost until your out-of-pocket spending reaches $8,550. After that, catastrophic coverage kicks in and you pay only 5% of the cost for the rest of the year. Because Prolia is given only twice a year, most people never reach the gap.

Medicare Advantage Plans and Prolia Coverage

Medicare Advantage plans (Part C) bundle hospital, doctor, and prescription drug coverage into one plan. Each Advantage plan sets its own formulary and its own copays or coinsurance for Prolia. Some plans cover Prolia with a $0 copay. Others charge $50 to $200 per injection. A few use coinsurance and charge you a percentage of the cost instead.

The key difference from Part D is that Advantage plans often have lower or no deductibles for drugs, and they cap your total out-of-pocket spending each year. Once you hit that cap (typically $6,700 to $7,550 in 2024), the plan pays 100% of your drug costs for the rest of the year. This can be an advantage if you take multiple expensive medications.

However, not all Advantage plans cover Prolia at all. Some formularies exclude it or require prior authorization — a step where your doctor must prove to the plan that you need Prolia before the plan will pay. If your current Advantage plan does not cover Prolia or charges a high copay, you can switch to a different Advantage plan during open enrollment (October 15 to December 7 each year) or switch to Original Medicare with Part D.

What Happens If You Have No Drug Coverage

If you have Original Medicare but no Part D plan, or if you have an Advantage plan that does not cover Prolia, you pay the full pharmacy price out of pocket. This is typically $1,500 to $2,000 per injection. At six-month intervals, that means $3,000 to $4,000 per year.

Before paying full price, check whether the manufacturer (Amgen) offers a patient information program. Amgen's Prolia Savings Program can reduce your cost to as little as $0 to $50 per injection if you meet income limits. You explore through Amgen's website or by phone, and the program works alongside Medicare or without it. This program is separate from your insurance and does not count toward your deductible or out-of-pocket maximum.

If you are uninsured or underinsured, also ask your doctor's office about samples or whether they can refer you to a local health center that offers sliding-scale pricing. Some community health centers negotiate lower drug prices for uninsured patients.

How to Find Your Exact Prolia Cost Before You Fill It

Your plan's website has a drug price tool — usually called a "formulary search" or "price estimator." Log in with your Medicare number, search for "denosumab" (Prolia's generic name), and the tool will show you the tier, copay, and whether prior authorization is required. This takes five minutes and gives you the real number you will pay.

If you cannot find it online, call your plan's customer service number (on the back of your insurance card). Tell them you want to know the copay for Prolia and whether it requires prior authorization. Write down the copay amount and the name of the representative who told you, in case there is a billing error later.

You can also call the pharmacy where you plan to fill it and give them your insurance information. The pharmacy can tell you the copay before you pick up the injection. This is especially useful if you are comparing costs across different pharmacies, since some chains negotiate different prices with Medicare.

Prior Authorization and Other Barriers to Coverage

Many Medicare plans require prior authorization for Prolia, meaning your doctor must submit paperwork to the plan proving that you have osteoporosis and that other treatments have failed or are not suitable for you. This step can delay your first injection by one to two weeks. Your doctor's office usually handles this, but you should ask them to submit it as soon as your doctor decides you need Prolia.

Some plans also require you to try and fail a cheaper osteoporosis drug first — usually a bisphosphonate like alendronate (Fosamax) — before they will cover Prolia. This is called a step therapy requirement. If you have already tried and failed a bisphosphonate, tell your doctor, because that history makes the prior authorization faster.

If your plan denies coverage, you have the right to appeal. Your doctor can file an appeal on your behalf, and Medicare requires the plan to respond within 72 hours for urgent cases. If the appeal is denied, you can request an independent review from an outside reviewer not employed by your plan.

Comparing Your Options During Open Enrollment

Every October, Medicare holds open enrollment (October 15 to December 7). This is the only time most people can switch plans without a penalty. If your current plan's Prolia copay is high, or if the plan requires prior authorization or step therapy, you can switch to a different Part D plan or a different Advantage plan with better coverage.

Use Medicare's Plan Finder tool at Medicare.gov. Enter your medications (including Prolia), your pharmacy, and your zip code. The tool will show you all available plans, their copays for your drugs, and their total estimated costs for the year. Compare at least three plans before deciding. Pay attention not just to Prolia's copay but to your copays for any other medications you take, since switching plans to save on one drug might cost you more on others.

If you miss open enrollment, you can still switch plans if you have a may have access to life event — moving to a new state, losing other insurance, or a change in your income. Call Medicare at 1-800-MEDICARE to ask whether your situation qualifies.

Frequently Asked Questions

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

Medicare covers Prolia for both prevention and treatment of osteoporosis in postmenopausal women and in men at high risk of fracture. Your doctor must document that you have low bone density (measured by a DEXA scan) or a history of fracture. Coverage does not depend on whether you are preventing future fractures or treating existing bone loss.

What if my doctor gives me Prolia in the office instead of at a pharmacy?

If your doctor injects Prolia in the office, Medicare Part B covers the injection itself (the doctor's fee and supplies). The drug cost is still covered under Part D or your Advantage plan's drug benefit. You pay your copay to the pharmacy or doctor's office, depending on how they bill it. Ask your doctor's billing staff whether they bill the drug to your insurance or whether you pick it up at a pharmacy first.

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

You cannot use a GoodRx coupon or other discount card if you have Medicare. Federal law prohibits using discount cards alongside Medicare coverage. However, if your Medicare copay is very high, you can ask your doctor whether a generic bisphosphonate might work for you instead, since generics have much lower copays. You can also look into the manufacturer's patient information program, which works alongside Medicare.

Will my Prolia copay change next year?

Yes. Plans change their formularies and copays every year on January 1. Your current copay is may provide only through December 31. During open enrollment in October, check your plan's new formulary for 2025 to see whether Prolia's copay is going up, down, or staying the same. If it is going up significantly, that is a good reason to shop for a different plan.

What if I cannot afford my Prolia copay?

Talk to your doctor or their financial counselor about the Amgen Prolia Savings Program, which can reduce your copay to $0 to $50 per injection. You can also ask whether your doctor has samples you can use while you explore for the program. If you are struggling with other medications too, ask about switching to a plan with lower copays during open enrollment, or ask your doctor whether a different osteoporosis drug with a lower copay might work for you.