Introduction
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If you’re a Medicare recipient and you’ve been prescribed Prolia for your osteoporosis, you may be wondering about your coverage options. Prolia is an injectable medication that is used to treat bone loss and reduce the risk of fractures. In this article, we will explore the coverage options for Prolia under Medicare in 2023.
What is Prolia?
Prolia is a medication that is used to treat osteoporosis in postmenopausal women and men who are at high risk of fractures. It is administered as an injection every six months and works by inhibiting the activity of cells that break down bone tissue.
Medicare Coverage for Prolia
Medicare Part B covers certain medically necessary injectable medications, including Prolia, when they are administered in a doctor’s office or outpatient facility. However, Medicare beneficiaries may be responsible for paying a portion of the cost of the medication, depending on their specific plan.
Original Medicare
If you have Original Medicare (Part A and Part B), your coverage for Prolia will depend on where and how you receive the injection. If you receive the injection in a doctor’s office or outpatient facility, you will typically be responsible for paying 20% of the Medicare-approved amount for the medication. If you receive the injection in a hospital outpatient setting, you may be responsible for paying a higher copayment or coinsurance amount.
Medicare Advantage
If you have a Medicare Advantage plan (Part C), your coverage for Prolia will depend on your specific plan. Some Medicare Advantage plans may cover Prolia with little or no out-of-pocket cost to you, while others may require a copayment or coinsurance.
Part D Coverage for Prolia
Medicare Part D is the prescription drug coverage program offered by Medicare. If you have a standalone Medicare Part D plan or a Medicare Advantage plan with prescription drug coverage, you may be able to obtain coverage for Prolia through your plan’s formulary.
Formulary Coverage
A formulary is a list of prescription drugs that are covered by a specific Medicare Part D plan. Prolia may be included on some formularies, but not all. If Prolia is not on your plan’s formulary, you may be required to pay the full cost of the medication.
Prior Authorization
Some Medicare Part D plans may require prior authorization before covering Prolia. This means that your doctor will need to submit information to your plan to show that the medication is medically necessary for your condition.
Appealing Coverage Denials
If your Medicare plan denies coverage for Prolia, you have the right to appeal the decision. The appeals process can take several weeks or months, but it may be worth pursuing if you believe that you are being denied coverage unfairly.
Conclusion
If you’re a Medicare beneficiary who has been prescribed Prolia for osteoporosis, it’s important to understand your coverage options. Medicare Part B covers Prolia when it is administered in a doctor’s office or outpatient facility, but you may be responsible for paying a portion of the cost. Medicare Part D may also provide coverage for Prolia, depending on your plan’s formulary. If your coverage is denied, you have the right to appeal the decision.
