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 meeting deductible‡,§
- 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 08/2022.
§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 | Accredo Health Group |
| Humana | CenterWell 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 01/20/2023. 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 2022 are included in this analysis.
- ‡The information is provided as a courtesy only and Amgen does not guarantee the accuracy of the information.
Helping eligible commercially insured patients lower out-of-pocket costs
The Amgen SupportPlus Co-Pay Program can help eligible commercially insured patients lower their out-of-pocket prescription costs, including deductible, co-insurance, and co-payment.*
- For Prolia®, pay as little as $25 out-of-pocket for each dose
- Can be applied to deductible, co-insurance, and co-payment*
Help patients enroll online at www.amgensupportplus.com/copay or by phone at 1-866-264-2778
*Eligibility criteria and program maximums apply. See www.amgensupportplus.com/copay for full Terms and Conditions.
Please see Important Safety Information below.
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 | Accredo Health Group |
| Humana | CenterWell 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 01/20/2023. For the most up-to-date and complete information, please refer to a patient’s health plan regarding specific policies, instructions, and requirements.
Important Safety Information
- Take the medicine XGEVA® (denosumab)
- Have low blood calcium
- Cannot take daily calcium and vitamin D
- Had parathyroid or thyroid surgery (glands located in your neck)
- Have been told you have trouble absorbing minerals in your stomach or intestines (malabsorption syndrome)
- Have kidney problems or are on kidney dialysis
- Are taking medicine that can lower your blood calcium levels
- Plan to have dental surgery or teeth removed
- Are pregnant or plan to become pregnant
Females who are able to become pregnant:- Your healthcare provider should do a pregnancy test before you start treatment with Prolia®.
- You should use an effective method of birth control (contraception) during treatment with Prolia® and for at least 5 months after your last dose of Prolia®.
- Tell your doctor right away if you become pregnant while taking Prolia®.
- Are breast-feeding or plan to breast-feed
What are the possible side effects of Prolia®?
It is not known if the use of Prolia® over a long period of time may cause slow healing of broken bones. The most common side effects of Prolia® in women being treated for osteoporosis after menopause are back pain, pain in your arms and legs, high cholesterol, muscle pain, and bladder infection.
The most common side effects of Prolia® in men with osteoporosis are back pain, joint pain, and common cold (runny nose or sore throat).
The most common side effects of Prolia® in patients with corticosteroid-induced osteoporosis are back pain, high blood pressure, lung infection (bronchitis), and headache.
The most common side effects of Prolia® in patients receiving certain treatments for prostate or breast cancer are joint pain, back pain, pain in your arms and legs, and muscle pain. Additionally, in Prolia®-treated men with nonmetastatic prostate cancer receiving ADT, a greater incidence of cataracts was observed.
These are not all the possible side effects of Prolia®. Call your doctor for medical advice about side effects.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.
Indications
Prolia® is a prescription medicine used to treat osteoporosis in women after menopause who are at high risk for fracture or cannot use another osteoporosis medicine or other osteoporosis medicines did not work well.
Prolia® is a prescription medicine used to increase bone mass in men with osteoporosis who are at high risk for fracture.
Prolia® is a prescription medicine used to treat osteoporosis in men and women who will be taking corticosteroid medicines (such as prednisone) for at least six months and are at high risk for fracture.
Prolia® is a prescription medicine used to treat bone loss in men who are at high risk for fracture receiving certain treatments for prostate cancer that has not spread to other parts of the body.
Prolia® is a prescription medicine used to treat bone loss in women who are at high risk for fracture receiving certain treatments for breast cancer that has not spread to other parts of the body.
Please see Prolia® full Prescribing Information and Medication Guide.