Prolia should be covered by Medicare Part A, Part B, or Part D, depending on why you need to take the drug and whether you will administer it yourself.
Prolia (denosumab) is an injectable monoclonal antibody medication prescribed to treat bone loss and osteoporosis. It’s administered as a liquid injection into the skin.
Specifically, it’s prescribed for adults who are more likely to develop bone fractures or, in some cases, to help increase bone density.
Read on to learn more about whether Medicare covers Prolia and how much it costs with Medicare coverage.
Yes, Medicare covers Prolia under certain conditions.
If you’re seeking coverage to treat postmenopausal osteoporosis, which increases the chance of fractures, you’ll need to show records of your diagnosis, previous fractures, former or current treatments, and treatment side effects.
If you’re seeking coverage to treat bone loss from breast cancer or nonmetastatic prostate cancer treatment, you’ll need to show evidence of your diagnosis, other diagnosed risk factors, and previous aromatase inhibitor therapy or androgen deprivation therapy.
In all cases, your prescribed dosage must always align with the Food and Drug Administration (FDA) label guidelines, or Medicare may deem it medically unnecessary.
You or your doctor will also need to show that you’re supplementing with at least 1,000 milligrams (mg) of calcium daily and 400 international units (IU) of vitamin D daily. This helps prevent a decrease in your calcium levels while you’re taking the drug.
Which Medicare part covers Prolia depends on the reason you are being prescribed the drug.
If the drug is prescribed for osteoporosis, Original Medicare’s Part B will provide coverage.
Part A may also pay for a nurse to come to your house to help you inject the drug if you’re eligible for home health services and your doctor certifies you’re unable to inject it yourself.
In addition, Medicare Part D may cover it if the drug is included in your specific plan’s formulary. According to the Prolia manufacturer, most Part D plans do cover the drug.
If you have Medicare Advantage, your coverage should be the same as Original Medicare. However, not every Advantage plan includes prescription drugs (Part D).
Out of pocket, Prolia costs $1,786.12 per injection.
If it’s getting covered under Part B, you will only need to pay 20% of the cost after you’ve met your deductible, which is $240 in 2024. You’ll also pay a monthly premium of $174.70.
If you need a healthcare worker to administer the drug, Part A should cover 100% of the cost.
If your coverage is under Part D, your cost will depend on your specific plan, which varies by location. You can find the plans in your area on Medicare.gov.
Medicare also covers denosumab under the brand name Xgeva for treating bone metastasis from cancerous tumors.
To get coverage, you’ll have to show that the treatment is necessary for managing hypercalcemia caused by your cancer and provide an explanation of why this drug was chosen for treatment.
Other injectable drugs for osteoporosis that Medicare may cover include:
Medicare may also cover bisphosphonates, such as:
Is there a cheaper alternative to Prolia?
Different medications have different costs. These costs depend on the drug and whether there are generic alternatives that may be cheaper.
In 2024, the FDA approved two biosimilar medications for denosumab called Jubbonti and Wyost. Medicare may cover them, though you may need to request prior authorization. Medicare Advantage may also cover them.
How do I bill Prolia to Medicare?
You don’t need to bill Medicare for a medication like Prolia. When Medicare processes a Part A claim, it pays the provider directly for the service.
With a Part B claim, who pays depends on whether the provider has accepted the assignment. If they have, Medicare covers 80% of the procedure cost, and you cover the remaining 20%.
It works similarly for Part C (Medicare Advantage) or Part D, except you’ll have to pay out of pocket if the doctor doesn’t accept the Medicare assignment.
Whether Medicare will cover Prolia depends on why you need to take it and how it will be administered.
If you are injecting it yourself for osteoporosis, Part B will cover Prolia. If you need a nurse to administer it to you at home, Part A will cover it. Some Part D plans may also cover Prolia.
To qualify for Medicare coverage, you’ll have to show evidence of a qualifying diagnosis of osteoporosis or certain types of cancer that can lead to bone loss, documentation of other treatments, and evidence of taking calcium and vitamin D supplements.
Your doctor will also need to prescribe dosages that align with FDA recommendations.