Is Prolia Covered by Medicare?

PThe National Osteoporosis Foundation reports that roughly 10 million Americans have osteoporosis and that an additional 44 million people suffer from decreased bone density and may develop the disease in the future. Osteoporosis puts you at an increased risk for debilitating fractures, but there are treatments available to lower the likelihood of injury due to a fall or other accident.

Prolia is approved by the U.S. Food and Drug Administration (FDA) to treat bone loss and minimize fracture risk. In many cases, Medicare covers Prolia to make treatment more affordable.

What Is the Prolia Injection Price?

Most commercial and Medicare plans include coverage for Prolia. The listed price assigned to Prolia amounts to $1,624.54, for each injection administered every six months. However, the majority of patients do not pay full price. It is recommended to engage with your insurance provider for detailed information.

Is Prolia Covered By Medicare?

Most Medicare plans cover Prolia and other osteoporosis injectable drugs. Although the list price for Prolia is upwards of $1,500 per every six month injection, but most patients do not pay that price is Prolia is covered by their Medicare plan.

When Does Medicare Pay for Prolia?

Prolia is often covered by Medicare Part A or Part B, together referred to as "Original Medicare." Which part of Medicare provides coverage and how much you can expect to pay out of pocket for the treatment depends on numerous factors, but Part B is usually what covers Prolia.

Original Medicare typically covers osteoporosis injectable drugs like Prolia and a home health nurse visit to inject the drug if you meet certain eligibility requirements:

• You must be a woman
• You must be eligible for Medicare Part B and have paid your premium
• You must have suffered a bone fracture related to osteoporosis

In addition, Medicare Part A may cover the cost of visits from a home health worker to administer the drug if your doctor writes a letter stating that you are unable to administer it yourself and any family members who reside with you are unable or unwilling to give you the injections.

What Does Prolia Do?

Throughout your life, your body breaks down existing bone and builds new bone in its place to keep your skeleton strong. Osteoclasts are the cells that drive the process. As you age, the bone-building process slows down while the work of osteoclasts continues at the same pace. This leads to a loss of bone density. Prolia is an injectable medication that works by disrupting the activation of osteoclasts to slow down bone loss.

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Who May Need Prolia?

Your doctor may prescribe Prolia if:

• You are a man or woman with low bone density at risk for developing osteoporosis
• You have been diagnosed with osteoporosis
• You have undergone treatment for prostate or breast cancer that has weakened your bones

How Much Does Prolia Cost Per Year?

The list price for one dose of Prolia was around $1,540 as of October 2023, according to Amgen, the manufacturer of the drug. Most people get one Prolia injection every six months, making the average cost for one year of treatment around $3,080, if you don't have insurance or Medicare coverage. You may pay more or less depending on where you live and choose to fill your prescriptions.

If you have Medicare, you may be responsible for copay or coinsurance costs, depending on your Medicare coverage.

• If you have Original Medicare, a Medicare Supplement plan (also called Medigap) can help fill your Medicare "gaps" and can help pay your out-of-pocket Medicare costs like copays and deductibles.
• If you have a Medicare Advantage plan with prescription drug coverage or a Medicare Part D prescription drug plan (PDP), your coinsurance costs and deductible may vary depending on your plan.

Be sure to speak directly with your plan provider insurance company to find out if and how your plan covers Prolia. If you're looking for a new Medicare Advantage plan with drug coverage or a new Part D drug plan that may cover Prolia, you can compare plans online for free or request a free plan quote from a licensed insurance agent.

What Part of Medicare Pays for Prolia?

For those who meet the criteria prescribed above, Medicare Part B covers Prolia. If you don't meet the above criteria, your Medicare Part D plan may cover the drug. GoodRx reports that 98% of surveyed Medicare prescription plans cover Prolia. With Medicare Part D coverage, you’re likely to pay coinsurance or a copay.

Is There a Generic Version of Prolia?

Denosumab is a generic alternative to Prolia. Denosumab also serves as the generic form of Xgeva, which is a drug identical to Prolia that is used to treat skeletal-related events in patients with multiple myeloma and bone metastases. 

Denosumab costs may be slightly less than that of Prolia due to its generic nature.

What Tier Is Prolia?

Your Medicare Part D plan has a formulary that spells out which drugs it covers. In the formulary, drugs are divided into the following tiers:

• Tier 1: The cheapest generic drug for a specific condition
• Tier 2: Other generic drugs for that condition
• Tier 3: The cheapest brand name drug that treats the condition and has no generic equivalent
• Tier 4: Other brand name drugs for the condition
• Tier 5: Experimental or specialty drugs for a condition

Because Prolia is a brand name drug with no generic equivalent, it typically falls under Tier 3 or 4. Consult your Medicare prescription drug plan's formulary for more information.

How Much Does Prolia Cost With Medicare?

If you qualify for coverage for Prolia under Medicare Part B, your plan will typically pay 80% of the injection while you pay the remaining 20%. Based on the list price of the drug, the 20% coinsurance would amount to roughly $250. You'll usually need to satisfy your Medicare Part B deductible before your plan will cover the drug.

Under Medicare Part D, the amount you'll have to pay out of pocket depends on the terms of your plan, what tier your plan classifies the drug as and what stage of coverage you're in.

• Deductible stage. Until you satisfy your plan's deductible, you will usually need to pay the full price for Prolia.
  
  
• Post-deductible stage. After you have met your deductible, your plan will typically pay for some or most of the cost of the drug, leaving you responsible for a copay.
  
  
• Donut hole. Once your total drug spending reaches the threshold for your plan's coverage gap or donut hole, you'll generally be responsible for 25% of the cost of Prolia.
• Post-donut hole. After you and your plan have spent more than the upper limit for the donut hole, you'll enter catastrophic coverage, with your plan likely paying most of the cost of the drug while you are responsible for only a copay or coinsurance.

What Is the Alternative to Taking Prolia?

The FDA has approved another brand-name version of denosumab, called Xgeva. Your Medicare Part D plan might not cover the medication. If it does, your out-of-pocket price for Xgeva injections may cost more or less than Prolia, depending on where the drugs are classified on the formulary. 

Instead of Prolia, doctors may prescribe other drugs for people at risk of suffering fractures due to osteoporosis, such as:

• Bisphosphonates like alendronate, ibandronate, risedronate and zoledronic acid
• Bone-building medications like teriparatide, abaloparatide and romosozumab
• Hormone-related therapy like raloxifene