Under Original Medicare, Part B covers certain osteoporosis drugs, including injectable treatments like Prolia, under specific conditions:

• The patient must be a woman.
• The patient must be eligible for Part B and meet criteria for Medicare home health services.
• There must be a bone fracture certified by a doctor as related to postmenopausal osteoporosis.
• The doctor must certify that the patient is unable to self-administer the drug by injection and that family members or caregivers are unable and unwilling to administer the drug.

If these conditions are met, Prolia is covered by Medicare Part B. After meeting the Part B deductible, patients typically pay 0% to 20% of the Medicare-approved amount for the drug. The cost of home health nurse visits to administer the drug is usually fully covered​​.

 Does Medicare Part D cover Prolia?

Around 95% of beneficiaries with Medicare Part D have access to Prolia. The average cost out-of-pocket is about $257 every six months, which isn’t too bad. But remember, each plan is different, so check yours to see exactly what’s covered and what your share of the cost might be. Also, if you have a limited income and are having trouble affording Prolia, here’s a program called Extra Help for those with Medicare Part D, which could ease the burden of medication costs​​​​.

Is Prolia covered by Medicare Advantage plans?

Medicare Advantage plans, also known as Part C, usually include drug coverage. In 2023, a whopping 98% of these plans covered Prolia. But keep in mind, costs like copays and deductibles can vary a lot between plans. It’s a good idea to dig into the details of your plan to see how it handles Medicare coverage for Prolia​​.

Does Medicare require prior authorization for Prolia?

For those on Medicare Part B, getting Prolia Medicare coverage as initial therapy is usually hassle-free—no need for step edits or prior authorizations, except in specific cases like with First Coast Service Options-Jurisdiction N (MAC B), where they ask for both​​​​. This indicates that patients can access Prolia without having to try other medications first or obtain specific approval from Medicare before starting treatment​​.  

However, when considering Medicare Part D, the situation might vary. While approximately 50% of Medicare Part D beneficiaries do not need prior authorization for Prolia, the need for prior authorization can depend on the specific plan and the individual’s circumstances. Therefore, it’s advisable for patients to verify the requirements with their Medicare Part D provider to understand the specific terms of their coverage​​. 

How often will Medicare pay for Prolia injections?

Medicare normally pays for Prolia injections every six months, aligning with the recommended treatment frequency. The coverage specifics depend on your plan, but most are on board with this schedule​​.

How much does Prolia cost with Medicare?

Costs for Prolia Medicare coverage can vary. With Part B, once you’ve hit your deductible, you’re looking at paying 0% to 20% of the Medicare-approved amount. According to official Amgen information, 81% of Part B beneficiaries pay $0 for the drug after meeting an annual deductible, which is $240 in 2024. And if you need a home health nurse for the injection, that’s usually covered in full by Medicare​​​​.

With Medicare Part D, the average cost for a beneficiary is $257 every 6 months.

Prolia assistance for Medicare patients

Assistance for drug injection

Medicare also assists with the costs of administering Prolia. If a patient requires a home health nurse to inject the drug and meets certain conditions, such as being homebound and under a doctor’s care, Medicare Part B may help cover this service. This assistance is crucial for those who are unable to self-administer the drug or do not have a family member or caregiver who can assist​​.

Amgen financial support programs

Beyond Medicare coverage, various assistance programs can help defray the costs associated with Prolia treatment. Amgen, the manufacturer of Prolia, offers Amgen SupportPlus, which provides financial support information and resources regardless of the patient’s financial situation or type of insurance. This program is available to patients with government insurance like Medicare and aims to lower out-of-pocket costs. For those who are uninsured or underinsured, the Amgen Safety Net Foundation, a nonprofit patient assistance program, helps qualifying patients access Amgen medicines at no cost​​​​.

Prolia coupons for Medicare patients do not exist

Despite whether Prolia is covered by your Medicare, you may still be looking to cut down on the cost. Though you might find coupons for Prolia, they can’t normally be combined with Medicare or other federal programs. But exploring options like Amgen SupportPlus could offer alternative ways to reduce costs for eligible patients and get Medicare coverage for Prolia.

Prolia alternatives

While Prolia is a popular choice for osteoporosis treatment, there are several alternatives available, particularly for those who might not be able to take Prolia or are looking for different treatment options:

Bisphosphonates

These are usually the first-line treatment for osteoporosis. They include: 

• Alendronate (Fosamax), taken as a weekly pill.
• Risedronate (Actonel), available as a weekly or monthly pill.
• Ibandronate (Boniva), which can be taken as a monthly pill or a quarterly intravenous (IV) infusion.
• Zoledronic acid (Reclast), administered as an annual IV infusion​​.
• Denosumab (Xgeva): This is another form of treatment for osteoporosis. It’s unrelated to bisphosphonates and might be used in cases where a patient can’t take bisphosphonates, such as individuals with reduced kidney function​​.

Other Medications

• Teriparatide (Forteo)
• Abaloparatide (Tymlos)
• Romosozumab (Evenity)​​ 

These alternatives provide different modes of administration and frequency, catering to the diverse needs and medical conditions of patients with osteoporosis. It’s important for patients to discuss with their healthcare providers to determine the most suitable treatment option based on their specific health status and preferences.