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Does Amerigroup Cover Prolia

Explore Prolia coverage by Amerigroup. Learn why coverage might be denied, how to secure it, costs without insurance, and find answers to common questions.

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Coverage for Prolia

Amerigroup generally covers Prolia under its Medicare Advantage plans, primarily for individuals with specific health needs.

It's typically covered for patients with osteoporosis at high risk for fractures, especially when other treatments have proven ineffective.

Criteria for Coverage

A diagnosis of osteoporosis and a history of osteoporotic fractures can make you eligible for coverage.

Physician documentation of high fracture risk or intolerance to alternative osteoporosis treatments may be required.

Prior authorization might be necessary, with detailed medical records to support the need for Prolia.

Basic Rules

Coverage varies by plan, so it's essential to check specific plan details and consult with Amerigroup directly.

Out-of-pocket costs may apply, depending on the plan's co-payments, deductibles, and pharmacy benefits.

It's advisable to consult your healthcare provider and Amerigroup for comprehensive guidance.

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Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

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At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

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Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Prolia Coverage with Amerigroup

Start by Checking Your Insurance Benefits

Contact Amerigroup's customer service using the number on your insurance card. Inquire if Prolia is covered under your current plan.

Review the benefits booklet provided by Amerigroup to see if Prolia is listed under covered medications.

Consult with Your Healthcare Provider

Speak with your doctor or a healthcare provider about the medical necessity of Prolia. Ensure they have documented reasons for prescribing it.

Ask your healthcare provider to provide you with any necessary documentation that Amerigroup might require, such as a letter of medical necessity.

Gather Required Documentation

Obtain a prescription for Prolia from your healthcare provider.

Collect any additional documents Amerigroup may require, such as prior authorization forms or letters of medical necessity.

Submit a Prior Authorization Request

Work with your healthcare provider to complete any Amerigroup-specific prior authorization forms for Prolia.

Submit the completed prior authorization form along with any supporting documentation to Amerigroup as specified in their guidelines.

Ensure all information is accurate to avoid delays in the approval process.

Follow Up on Your Request

After submission, monitor the status of your prior authorization request by contacting Amerigroup directly.

If there are any issues or additional information is needed, promptly provide what is required to facilitate the process.

Understand Your Coverage and Costs

Once approved, review the details of your Prolia coverage, including co-pays or co-insurance amounts, by checking your Amerigroup plan details or speaking with a representative.

Clarify any potential out-of-pocket costs you might face, so you are prepared financially.

Fill Your Prescription

Take your approved prescription to a pharmacy that is in-network with Amerigroup.

Verify with the pharmacy that they have received authorization for Prolia and check the copayment amount before purchase.

Appeal if Necessary

If your request is denied, review the denial letter from Amerigroup to understand the reasons.

Consult with your healthcare provider to address the reasons for denial and gather any additional documentation needed.

File an appeal with Amerigroup, following their procedures for reconsideration. Be sure to submit all necessary paperwork by the stated deadlines.

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FAQs

Does Amerigroup Cover Prolia

Explore Prolia coverage by Amerigroup. Learn why coverage might be denied, how to secure it, costs without insurance, and find answers to common questions.

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Is Prolia Covered by Amerigroup

Coverage for Prolia

Amerigroup generally covers Prolia under its Medicare Advantage plans, primarily for individuals with specific health needs.

It's typically covered for patients with osteoporosis at high risk for fractures, especially when other treatments have proven ineffective.

Criteria for Coverage

A diagnosis of osteoporosis and a history of osteoporotic fractures can make you eligible for coverage.

Physician documentation of high fracture risk or intolerance to alternative osteoporosis treatments may be required.

Prior authorization might be necessary, with detailed medical records to support the need for Prolia.

Basic Rules

Coverage varies by plan, so it's essential to check specific plan details and consult with Amerigroup directly.

Out-of-pocket costs may apply, depending on the plan's co-payments, deductibles, and pharmacy benefits.

It's advisable to consult your healthcare provider and Amerigroup for comprehensive guidance.

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Amerigroup's Approved Criteria for Prolia Coverage

Eligibility Criteria for Prolia Coverage

Diagnosed with postmenopausal osteoporosis with a high risk of fracture.

Men with osteoporosis who have a high risk of fracture.

Patients with glucocorticoid-induced osteoporosis with a high fracture risk who have failed or are intolerant to other osteoporosis therapies.

Treatment of bone mass loss in men and women receiving androgen deprivation therapy for prostate cancer or adjuvant aromatase inhibitor therapy for breast cancer, respectively, and who are considered at high risk for fractures.

Documentation and Diagnosis Requirements

Clinical documentation of osteoporosis diagnosis through bone mineral density tests or history of osteoporotic fractures.

Detailed patient medical history indicating prior fractures or existing bone conditions that contribute to a higher fracture risk.

Evidence of intolerant reactions or failure to previous osteoporosis therapies if applicable.

Prescribing Physician Criteria

Must be prescribed by a healthcare provider specializing in osteoporosis or related conditions, such as an endocrinologist, rheumatologist, or orthopedic specialist.

The prescribing physician should provide a comprehensive treatment plan indicating the necessity of Prolia for the patient’s condition.

Patient Compliance and Monitoring

Patients must comply with Amerigroup’s monitoring protocols, including regular follow-ups and bone density assessments as recommended by the healthcare provider.

Patients need to demonstrate adherence to supplementary treatment measures, such as calcium and vitamin D intake as recommended during Prolia treatment.

Renewal and Continuation of Coverage

Continued coverage requires documented clinical response or stabilization of osteoporosis as assessed by the healthcare provider.

Progress and adherence to treatment must be assessed regularly, with results submitted to Amerigroup for ongoing coverage assessment.

Annual re-evaluation by the healthcare provider is necessary to justify the need for continued Prolia therapy.

Why Amerigroup Might Deny Prolia Coverage

Reasons Amerigroup Might Deny Prolia Coverage

The patient does not meet the medical criteria defined by Amerigroup, such as not having a confirmed diagnosis that aligns with the drug’s approved uses.

The request for Prolia is not supported by the necessary documentation or medical history required for approval.

The medication is being prescribed for an off-label use that is not covered under Amerigroup’s policy.

The patient does not satisfy the requirements for prior authorization, or the request lacks a prior authorization submission.

Prolia is being requested as a first-line therapy when Amerigroup guidelines specify other treatments should be tried first without success.

The prescription is being requested in a dosage or form that is not covered under Amerigroup’s formulary guidelines.

The patient does not meet the age or gender specifications outlined in the Amerigroup policy for Prolia coverage.

There is insufficient evidence of medical necessity or the provided evidence does not justify the need for the treatment.

The claim falls under a benefit category that excludes coverage for the drug.

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How Much Does Prolia Cost without Insurance?

Prolia Cost Without Insurance

Prolia (denosumab) is a prescription medication primarily used to treat osteoporosis in postmenopausal women and men at high risk of fractures. Without insurance, the cost of Prolia can be significant.

The approximate cost for a single 60mg/ml injection of Prolia is around $1,500 to $2,000. This price may vary based on location, pharmacy pricing, and additional dispensing fees.

It's important to note that prices can fluctuate and might be subject to discounts or coupons offered by pharmacies or through the manufacturer's patient assistance programs.

Patients without insurance coverage for Prolia might also consider reaching out to Amgen, the manufacturer, for potential cost-assistance programs or savings options that may be available.

Pharmacies, including major chains and independent stores, may offer price matching or competitive pricing, so it's advisable to compare prices across different providers.

Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

Jill Hamburg, PA - C

Immunotherapy made simple. We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Kayla Mardaga, NP

How to Get Prolia Coverage with Amerigroup

Start by Checking Your Insurance Benefits

Contact Amerigroup's customer service using the number on your insurance card. Inquire if Prolia is covered under your current plan.

Review the benefits booklet provided by Amerigroup to see if Prolia is listed under covered medications.

Consult with Your Healthcare Provider

Speak with your doctor or a healthcare provider about the medical necessity of Prolia. Ensure they have documented reasons for prescribing it.

Ask your healthcare provider to provide you with any necessary documentation that Amerigroup might require, such as a letter of medical necessity.

Gather Required Documentation

Obtain a prescription for Prolia from your healthcare provider.

Collect any additional documents Amerigroup may require, such as prior authorization forms or letters of medical necessity.

Submit a Prior Authorization Request

Work with your healthcare provider to complete any Amerigroup-specific prior authorization forms for Prolia.

Submit the completed prior authorization form along with any supporting documentation to Amerigroup as specified in their guidelines.

Ensure all information is accurate to avoid delays in the approval process.

Follow Up on Your Request

After submission, monitor the status of your prior authorization request by contacting Amerigroup directly.

If there are any issues or additional information is needed, promptly provide what is required to facilitate the process.

Understand Your Coverage and Costs

Once approved, review the details of your Prolia coverage, including co-pays or co-insurance amounts, by checking your Amerigroup plan details or speaking with a representative.

Clarify any potential out-of-pocket costs you might face, so you are prepared financially.

Fill Your Prescription

Take your approved prescription to a pharmacy that is in-network with Amerigroup.

Verify with the pharmacy that they have received authorization for Prolia and check the copayment amount before purchase.

Appeal if Necessary

If your request is denied, review the denial letter from Amerigroup to understand the reasons.

Consult with your healthcare provider to address the reasons for denial and gather any additional documentation needed.

File an appeal with Amerigroup, following their procedures for reconsideration. Be sure to submit all necessary paperwork by the stated deadlines.

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Prolia FAQ

What are the side effects of Prolia?

Common Side Effects of Prolia

Back pain
Muscle pain
Joint pain
Increased cholesterol levels
Bladder infection

Serious Side Effects

Serious allergic reactions: Difficulty breathing and rash
Severe bone/joint/muscle pain
Low blood calcium levels
Jawbone problems (osteonecrosis)
Unusual thigh bone fractures

Important Notes

Always report any unusual symptoms to your healthcare provider.
Maintain regular follow-up appointments to monitor your health.
This is not an exhaustive list; consult your doctor or pharmacist for more information.

How long does Prolia stay in your system?

How Long Does Prolia Stay in Your System

Prolia, or denosumab, is a medication used for osteoporosis treatment. After administration, its active effects last around 6 months, which is why it's typically given bi-annually.

The drug's elimination from the body may take longer due to its biological nature and mechanism. Prolia is a monoclonal antibody and is mainly cleared through the reticuloendothelial system, involving processes like protein degradation.

An important factor is the half-life of Prolia, which averages 25 to 28 days. Complete clearance from the system can vary, potentially extending up to 9 months after the last dose.

Individual factors, such as metabolic rate and kidney function, can affect the duration Prolia remains detectable in the body. Consultation with a healthcare professional is advised to understand its impact on specific health concerns.

Is Prolia the same as Reclast?

Comparison of Prolia and Reclast

Prolia: A brand name for denosumab, Prolia is an injectable biophosphonate used to treat osteoporosis by inhibiting bone resorption. It's administered every 6 months as a subcutaneous injection.

Reclast: Known as zoledronic acid, Reclast is also a biophosphonate but given as an intravenous infusion. It works similarly by decreasing bone loss and is typically administered once a year.

Mechanism: While both drugs target bone resorption, Prolia and Reclast function differently at a cellular level. Prolia inhibits RANK ligand, while Reclast inhibits osteoclast activity.

Side Effects: Both medications may cause nausea, fatigue, and joint pain. However, Prolia can also lead to hypocalcemia, while Reclast may cause flu-like symptoms post-infusion.

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Initial Dosage

Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

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Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide. Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

Curex and its pharmacy partners do not have any association with Novo Nordisk.

Will I be prescribed semaglutide?

Your health journey is unique, and we tailor our care to match. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform. You can trust that your treatment plan will be personalized to fit your specific needs. And if semaglutide is not prescribed, we will provide a full refund.

What is compounded medication?

Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.

These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.

Is compounded medication the same as generic medication?

Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.

Is insurance required?

No, Curex doesn’t require insurance. We offer clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health.

Can I pay with an FSA or HSA card?

Yes! You can pay with your HSA or FSA card.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. We don’t prescribe Ozempic®* or Wegovy®.* We may prescribe treatments containing compounded semaglutide or tirzepatide. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.

Are video visits with a provider required?

Our providers will review your information 100% online. Depending on where you live and the specifics of your medical history, our providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.

What states do you serve?

Currently, we do not serve Arkansas, Connecticut, and New Mexico. However, we are always working to expand our reach, so stay in touch with us at hi@getcurex.com.

Does Amerigroup Cover Prolia

Explore Prolia coverage by Amerigroup. Learn why coverage might be denied, how to secure it, costs without insurance, and find answers to common questions.

Achieve Your Goals Faster with Curex