Original Medicare (Part A and Part B), Part D, and Medicare Advantage typically offer coverage for the osteoporosis drug Prolia. However, individuals must meet certain requirements for Part B coverage.
Medicare covers various osteoporosis drugs. The part of Medicare that will provide coverage depends on certain circumstances and criteria.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare typically covers osteoporosis drugs, such as Prolia. The amount covered depends on the Medicare part providing the coverage and the person’s plan.
Original Medicare
Part A covers inpatient hospital care, skilled nursing facilities, and home health services. Part B covers outpatient medical services, such as doctor’s visits, durable medical equipment, and preventive services, such as vaccines.
Original Medicare will offer coverage for Prolia if a person meets certain criteria.
The coverage criteria includes:
- having a fracture that is related to postmenopausal osteoporosis
- meeting the requirements for Medicare home health services, such as being unable to leave home
- having certification from a healthcare professional that the individual cannot give themselves the injection or that their family members are unable or unwilling to give the injection
Read about Original Medicare.
Part D
Medicare Part D is optional prescription drug coverage. Private Medicare-approved insurance companies provide these plans.
Each Part D plan has its own drug list or formulary, which lists all the prescription drugs it provides coverage for.
Most Part D plans will include Prolia on their formulary. Around 95% of all Part D beneficiaries receive coverage for Prolia.
Costs and coverage vary by plan. Individuals should check with their provider or healthcare professional for more information.
Medicare Advantage
Medicare Advantage (Part C) is an alternative to Original Medicare. These plans are provided by private insurance companies.
They must offer the same coverage as Part A and Part B. Many Medicare Advantage plans also offer prescription drug coverage (Part D).
This means that generally, Medicare Advantage plans will cover osteoporosis drugs, such as Prolia. However, a person should check with their plan provider for coverage information.
Read about Original Medicare vs. Medicare Advantage.
A note about sex and gender
Sex and gender exist on spectrums. This article will use the terms “male,” “female,” or both to refer to sex assigned at birth. Click here to learn more.
Prolia (denosumab) is an injectable medication that helps treat osteoporosis. Osteoporosis is a condition that causes the bones to become thin and weak, leading to a higher risk of fractures and breaks.
Healthcare professionals typically prescribe Prolia to the following individuals:
- postmenopausal females with osteoporosis and a higher risk of fractures
- males who have a higher risk of bone fractures or who have not responded to other osteoporosis treatments
- individuals who have taken corticosteroids for at least 6 months and developed osteoporosis
- males who have undergone treatment for prostate cancer and experienced bone loss
- females who have undergone treatment for breast cancer and experienced bone loss
Prolia is typically given by injection once every 6 months.
According to the Prolia website, the average cost is $1,786.12 per injection.
However, Original Medicare typically covers 80% of the cost of Prolia. This means the individual is responsible for 20% of the total cost. They are also responsible for paying the monthly Part B premium, which is $174.70 for most people in 2024.
Since both Part D plans and Medicare Advantage are provided by private insurance companies, the costs for prescription drugs may vary. Individuals should check with their individual plans for more information on out-of-pocket costs.
Read more about the cost of Prolia.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Original Medicare (Part A and Part B), Part D, and Medicare Advantage generally offer coverage for osteoporosis drugs, such as Prolia.
Original Medicare may provide coverage if a person is postmenopausal with a fracture and requires a healthcare professional to administer the injection.
Most Part D and Medicare Advantage plans will provide coverage for Prolia. However, individuals should check with their plan formulary for the exact drugs that are covered.