Tillie Doyle
Prolia (denosumab) is a prescription medication used to treat osteoporosis in postmenopausal women and men at high risk for fracture. It is a biologic drug, meaning it is made from living cells, and is administered via injection. The list price for Prolia is $1,875.43 per injection every six months, but most patients do not pay this price. The cost of Prolia may be covered by insurance plans, including Medicare and Medicaid. In particular, Medicare Part D, which is the primary source of drug coverage for dual-eligible beneficiaries covered under both Medicare and Medicaid, covers Prolia. However, out-of-pocket costs and insurance requirements may vary, and patients should consult their insurance providers to understand their specific coverage and costs. Additionally, the Patient Access Network Foundation (PAN) may be able to assist patients who are struggling to afford the copays or deductibles for Prolia.
| Characteristics | Values |
|---|---|
| Prolia price | $1,875.43 per injection every six months |
| Medicare Part B covers | 80% of therapies received in the doctor's office |
| Medicare Part D | Primary source of drug coverage for "dual eligible" beneficiaries covered under both Medicare and Medicaid |
| Patient Access Network Foundation (PAN) assistance criteria | Income is below 400% of the federal poverty line, Prolia is prescribed for an approved FDA indication |
| Amgen's SupportPlus Co-Pay Program | Eligible commercially insured patients pay as little as $25 out-of-pocket for each dose |
| Medicare Advantage (Medicare Part C) | Offered by private health insurance companies |
| Medicare Part D plans | Some have a preferred specialty pharmacy |
| Medicare Part D Standard patients | Received Prolia injection through Pharmacy Medicare Part D channel |
| Prolia prescription rules | Prescription at a pharmacy that has been certified to participate in the Prolia REMS program, doctor must be certified to prescribe Prolia |
| Prolia co-pay | $1540.19 |
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What You'll Learn
Medicare Part D covers Prolia
Prolia (denosumab) is a medication used to treat osteoporosis and increase bone mass in men and women at high risk of fractures. It is also used to treat patients with glucocorticoid-induced osteoporosis and those receiving certain cancer treatments.
The cost of Prolia under Medicare Part D can vary depending on your specific plan and whether you obtain the medication through a medical benefit or pharmacy benefit. Some Medicare Part D plans have preferred specialty pharmacies, which can impact where you fill your Prolia prescription. Additionally, if you have limited income, you may qualify for Extra Help, a program that assists with medication costs through Medicare Part D.
If you have both Medicare and Medicaid ("dual eligible"), Medicare Part D serves as the primary source of drug coverage. In this case, you can benefit from the Amgen® SupportPlus Co-Pay Program, which helps eligible commercially insured patients lower their out-of-pocket costs for Prolia, including deductibles, co-insurance, and co-payments.
If you are facing challenges in paying for Prolia due to high out-of-pocket expenses, there are additional support options available. The Patient Access Network Foundation (PAN) and the HealthWell Foundation offer assistance programs to help with medication costs. These programs have specific eligibility criteria, so it is important to review the requirements before applying.
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Medicaid may cover the full cost
Medicare Part D is the primary source of drug coverage for "dual-eligible" beneficiaries covered under both Medicare and Medicaid. However, patient out-of-pocket costs and insurance requirements may vary. To determine whether Medicaid covers Prolia in a particular state, individuals can visit the government website Healthcare.gov and select their state to navigate to the appropriate contact point for making an application.
Individuals who are insured with Medicare and find the Prolia drug savings options unaffordable can check their Medicaid eligibility. If Medicaid denies coverage for Prolia, individuals may still be eligible for federal support programs, such as the Low-Income Subsidy, which is available to residents of the 50 states and the District of Columbia.
Additionally, there are other organizational support programs that can assist with the cost of Prolia. The Patient Access Network Foundation (PAN) may be able to help individuals who are having trouble paying for Prolia due to unaffordable copays or deductibles. To qualify for PAN assistance, individuals must meet certain criteria, such as having an income below 400% of the federal poverty level and having Prolia prescribed for an approved FDA indication. The HealthWell Foundation Copay Program and the Patient Advocate Foundation's Co-Pay Relief Program are also options for those struggling with the financial burden of Prolia treatment.
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Patient Access Network Foundation (PAN) assistance
The Patient Access Network Foundation (PAN) is a charitable organization that provides financial assistance to help people afford their prescription medications. PAN was founded in 2004 and is headquartered in Washington, DC. It acts as a safety net for people living with chronic and rare diseases, helping them pay for their medications even if they have insurance coverage. PAN has earned a 4/4-star rating on Charity Navigator, indicating that it is a trustworthy and effective organization.
PAN's mission is to accelerate access to affordable and equitable healthcare through financial assistance, advocacy, and education. They aim to remove barriers to treatment and improve health outcomes for thousands of people each year across a broad range of health conditions. PAN continues to expand its financial assistance programs to provide access to life-saving treatments for people with life-threatening, chronic, and rare diseases.
Regarding Prolia (denosumab), it is covered by the majority of commercial and Medicare plans, including Medicare Part B and Medicare Part D. However, out-of-pocket costs and insurance requirements may vary. If you are having trouble paying for Prolia due to unaffordable copays or deductibles, PAN may be able to assist you. To qualify for PAN assistance for Prolia, you will need to meet certain criteria, including having an income below 400% of the federal poverty level and having Prolia prescribed for an approved FDA indication.
Additionally, there are other support programs available to help with the cost of Prolia. The Amgen® SupportPlus Co-Pay Program can help eligible commercially insured patients lower their out-of-pocket prescription costs, including deductibles, co-insurance, and co-payments. The HealthWell Foundation Copay Program and the Patient Advocate Foundation's Co-Pay Relief program also offer financial assistance to those struggling to pay for their Prolia treatment.
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Amgen's SupportPlus Co-Pay Program
The Amgen SupportPlus Co-Pay Program is designed to help eligible commercially insured patients lower their out-of-pocket prescription costs. This includes costs such as deductibles, co-insurance, and co-payments. For Prolia, patients may pay as little as $25 out-of-pocket for each dose.
The program is applicable to patients with commercial insurance and Medicare Part D coverage. Medicare Part D is the primary source of drug coverage for "dual-eligible" beneficiaries covered under both Medicare and Medicaid. Patients with Medicare can also benefit from the program, especially if they have tried Medicaid and received a denial or have been denied the Low-Income Subsidy.
It is important to note that eligibility criteria and program maximums apply for the Amgen SupportPlus Co-Pay Program. To determine eligibility and understand the specific terms and conditions, patients can visit the AmgenSupportPlus website.
Additionally, there are other support programs available for patients who are struggling with the cost of Prolia. These include the Patient Access Network Foundation (PAN) assistance program, the HealthWell Foundation Copay Program, and the Patient Advocate Foundation's Co-Pay Relief Program. These programs aim to assist patients who are facing financial difficulties in paying for their Prolia medication.
The cost of Prolia can vary depending on the patient's insurance coverage and the specific Medicare plan they have. It is always recommended to consult with one's insurance provider to understand the exact out-of-pocket expenses and explore all available options for financial support.
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Medicare Part B covers 80% of therapies
Medicare Part B covers 80% of medically necessary services and supplies that meet accepted standards of medical practice to diagnose or treat a medical condition. This includes drugs and biologicals that cannot be self-administered, diagnostic tests, certain therapies such as x-ray, radium, and radioactive isotope therapy, and surgical dressings and devices for fractures. Preventive services, such as colorectal cancer screening, diabetes training tests, bone mass measurements, and prostate cancer screening, are also covered by Medicare Part B.
Medicare Part B helps fill some of the gaps in medical insurance coverage left under Part A. Once the beneficiary meets the annual deductible, Medicare Part B will cover 80% of the "reasonable charge" for covered services, with the beneficiary responsible for the remaining 20% as co-insurance. The "`reasonable charge`" is a rate set by Medicare and may be lower than the provider's actual charge, potentially resulting in out-of-pocket expenses for the patient.
When a physician accepts "assignment," they agree to accept the Medicare-approved "reasonable charge" as full payment, and the patient pays the 20% co-payment. However, if a physician does not accept assignment, they may "`balance bill`" the patient above the Medicare-approved charge, and the patient may be responsible for a larger portion of the bill.
Medicare Part B covers 80% of Prolia therapies received in a doctor's office, with the patient responsible for the remaining 20%. Patients can obtain additional insurance, such as a Medicare Supplement Plan or Medigap, to cover this additional cost. The cost of Prolia may vary depending on the type of Medicare plan and whether it is obtained through a distributor or a pharmacy.
Medicare Part D, on the other hand, is the primary source of drug coverage for "dual-eligible" beneficiaries covered under both Medicare and Medicaid. Some Medicare Part D plans have preferred specialty pharmacies for filling Prolia prescriptions, and patients with limited incomes may qualify for Extra Help to pay for medication costs through Medicare Part D.
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Frequently asked questions
Prolia (denosumab) is a medication used to treat osteoporosis in postmenopausal women and men. It is also used for people undergoing treatment for certain cancers that increase the risk of bone fractures.
Yes, Prolia is covered by Medicare Part D. However, out-of-pocket costs and insurance requirements may vary depending on the specific plan. It is recommended to consult a Medicare advisor to ensure coverage.
Yes, alternative sources of financial assistance for Prolia include the Patient Access Network Foundation (PAN), the HealthWell Foundation Copay Program, and the Patient Advocate Foundation's Co-Pay Relief Program. These organizations may be able to assist individuals who are struggling to afford the medication due to high copays or deductibles.
Yes, there are a few ways to potentially lower the cost of Prolia:
- Utilizing pharmacy coupons or cash prices, which may offer lower prices than insurance.
- Enrolling in the Amgen® SupportPlus Co-Pay Program, which can help lower out-of-pocket costs for commercially insured patients.
- Applying for Extra Help through Medicare Part D, a program designed to assist individuals with limited incomes in paying for medication costs.
