The cost of Prolia with Medicare can vary significantly depending on your specific Medicare plan and whether you have supplemental insurance.
Medicare Part B typically covers Prolia, but you'll likely have out-of-pocket costs.
In this guide, you'll learn:
How Medicare Part B covers Prolia.
The potential out-of-pocket costs.
Factors that influence the cost of Prolia.
How to find financial assistance.
Prolia (denosumab) is an injectable medication used to treat osteoporosis. Medicare Part B covers Prolia when it's administered in a doctor's office or outpatient clinic.
Part B Coverage: Prolia is covered as a Part B drug, meaning it's administered by a healthcare provider.
Medical Necessity: Your doctor must document that Prolia is medically necessary for your condition.
Part B Deductible: You must meet your annual Part B deductible before Medicare starts paying.
Coinsurance: After meeting the deductible, you'll typically pay 20% of the Medicare-approved amount for Prolia.
Administration Fees: There may be separate administration fees, which are also subject to the 20% coinsurance.
Several factors can influence the cost of Prolia with Medicare:
Medicare-Approved Amount: The amount Medicare approves for Prolia can vary.
Location: Costs can differ based on your geographic location.
Supplemental Insurance: Medigap or other supplemental insurance can help cover out-of-pocket costs.
Medicare Advantage (Part C): Medicare Advantage plans may have different cost-sharing structures.
Financial Assistance Programs: Manufacturer assistance programs or patient assistance programs may help lower costs.
If you're concerned about the cost of Prolia, consider these options:
Amgen SupportPlus: The manufacturer, Amgen, offers support programs that may provide financial assistance.
Patient Assistance Programs: Several organizations offer programs to help with medication costs.
State Pharmaceutical Assistance Programs (SPAPs): Check if your state offers assistance programs.
Extra Help (LIS): If you have limited income and resources, you may qualify for Extra Help to pay for Medicare drug costs.
Understanding how Medicare covers Prolia and the potential out-of-pocket costs can help you manage your osteoporosis treatment.
Exploring financial assistance options can further alleviate financial burdens.
For more insight into how this concept interacts with others, see our detailed guide on Medicare Part B, which further explores the overall structure of Medicare's outpatient medical insurance and its implications in greater depth.
Yes, the Prolia shot (denosumab) is typically covered under Medicare Part B.
Medicare Part B covers drugs administered in a doctor's office or outpatient clinic, which is how Prolia is given.
Getting Prolia completely "free" is rare, but here are some avenues to explore:
Manufacturer Assistance Programs: Amgen, the manufacturer of Prolia, may offer patient assistance programs for those who qualify based on income. Contact Amgen SupportPlus directly.
Patient Assistance Programs: Various charitable organizations and foundations provide assistance with medication costs.
Medicaid: If you qualify for Medicaid, it may cover some or all of the costs not covered by Medicare.
Extra Help (LIS): If you have limited income and resources, you may qualify for "Extra Help" to pay for Medicare drug costs.
It's important to understand that complete free coverage is unlikely, but these options can significantly reduce costs.
Yes, there are alternatives to Prolia, and some may be less expensive, but they may also have different side effects or administration methods. Discuss these options with your doctor:
Bisphosphonates: Oral medications like alendronate (Fosamax) or risedronate (Actonel) are often less expensive.
Zoledronic acid (Reclast): An intravenous bisphosphonate that is administered once a year.
Teriparatide (Forteo) and Abaloparatide (Tymlos): These are daily injections that stimulate bone formation.
The best choice depends on individual circumstances and medical history.
The cost of Prolia without insurance can be very high.
The price can vary depending on:
The pharmacy or healthcare provider.
The geographic location.
Whether there are any available discounts or coupons.
Without insurance, a single Prolia injection can cost several hundred to over a thousand dollars.
It is always best to contact your local pharmacy, or doctors office, for the most up to date pricing.