Prolia® is an injection administered by a healthcare professional and is covered by both Medicare Part B and Medicare Part D
What you pay will depend on your Medicare plan and whether your doctor orders Prolia® from a distributor (medical benefit) or gets it from a pharmacy (pharmacy benefit).
Ask your doctor how you can get Prolia®
If you are a Medicare Part B patient
of Medicare Part B patients have access to Prolia® as initial therapy*,†
- No step edit required
- No prior authorization required
Most Medicare Part B patients have additional insurance and could pay $0 per syringe of Prolia‡,§
- After you meet your deductible, Medicare Part B typically covers 80% of therapies you receive in your doctor’s office
- You can obtain an additional insurance (e.g., Medicare Supplement Plan or Medigap,
commercial, TRICARE) to pick up the additional 20%
- You may need to pay additional monthly premiums with these additional insurances. - Out-of-pocket costs do not include costs related to office visits or administration of Prolia®.
What you pay for Prolia® will depend on the type of Medicare plan you have. Talk to your insurance provider to find out what you will pay for Prolia®.
*All Medical Lives associated with Medicare FFS, Medicare Advantage, and Commercial Coverage Restriction for Prolia® in DRG Coverage snapshot as of 6/2021 included in this analysis.
†First Coast Service Options-Jurisdiction N (MAC B) requires a prior authorization and step edit.
‡Analysis includes Amgen Assist® insurance verification data for Prolia® prospective patients only from 11/2021 to 4/2022.
§The co-pay may depend on coverage of additional insurance plan.
If you are a Medicare Advantage (Medicare Part C) patient
Medicare Advantage is another way to get Medicare services and is offered by private health insurance companies.
- Cost and coverage vary by plan so it’s important to verify your insurance benefits and out-of-pocket costs for Prolia®
If you are a Medicare Part D patient
of Medicare Part D patients have access* to Prolia®†
Pharmacy patients: Some Medicare Part D plans have a preferred specialty pharmacy and some commercial plans require a specific specialty pharmacy for filling your Prolia® prescription.
Preferred Specialty Pharmacies** 
Some Medicare Part D plans have a preferred specialty pharmacy for filling prescriptions
| MEDICAL AND/OR PRESCRIPTION PLAN | PREFERRED SPECIALTY PHARMACY |
|---|---|
| Aetna | CVS Specialty |
| Express Scripts | Accredo Health Group |
| Cigna | Accredo Health Group |
| CVS Caremark | CVS Specialty |
| Highmark | Walgreens Specialty Pharmacy |
| Humana | Humana Specialty Pharmacy |
The pharmacies listed above are for information purposes only and may not be comprehensive of all available mandated specialty pharmacies for a particular plan. The information provided is not a guarantee of fulfillment. Information as of 9/30/2021. For the most up-to-date and complete information, please refer to a patient’s health plan regarding specific policies, instructions, and requirements.
If you have a limited income: Medicare beneficiaries may qualify for Extra Help, a program to help pay for medication costs through Medicare Part D. Visit the Medicare website to learn more about Extra Help.
Dual eligibility: Medicare Part D is the primary source of drug coverage for “dual eligible” beneficiaries covered under both Medicare and Medicaid.
- *Access is defined as the ability of a patient to obtain Prolia®, although patient OOP cost and insurance requirements may vary.
- †All Retail Lives associated with Medicare Part D coverage Restriction for Prolia® in DRG Coverage data snapshot as of Q2 2021 are included in this analysis.
- **The information is provided as a courtesy only and Amgen does not guarantee the accuracy of the information.
For eligible commercially insured patients
LOWER YOUR OUT-OF-POCKET COSTS WITH THE PROLIA® CO-PAY PROGRAM
How do I get started?
Follow these steps to enroll:
Visit ProliaSupport.com
or call 1-844-369-9962
Answer a few short questions to find out if you’re eligible and complete the Patient Authorization Form
Eligible patients will receive a letter in the mail welcoming them to the Prolia® Co-pay Program.
Eligible patients pay as little as
$25
per dose of Prolia®
- Pay as little as $25 for each dose of Prolia® up to an annual Maximum Program Benefit per calendar year*
- Applies to deductible, co-insurance, or co-pay for Prolia® but not costs associated with office visit for the administration of Prolia®.
- No income eligibility requirement
- Other restrictions apply. Visit ProliaSupport.com or call 1-844-369-9962 for more information about this program, including the Maximum Program Benefit and full Terms and Conditions.
How do I get started?
Follow these steps to enroll:
Visit ProliaSupport.com
or call 1-844-369-9962
Answer a few short questions to find out if you’re eligible and complete the Patient Authorization Form
Eligible patients will receive a letter in the mail welcoming them to the Prolia® Co-pay Program.
