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Does Anthem Cover Prolia

Explore Anthem's Prolia coverage, ways to get approved, and costs without insurance. Plus, find answers to common Prolia questions in our detailed guide.

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Does Anthem Cover Prolia?

Anthem may cover Prolia, but coverage varies based on specific plans and medical necessity criteria.

Typically, Prolia is covered for postmenopausal women with osteoporosis at high risk for fracture, men with osteoporosis at high risk for fracture, and patients with bone loss due to hormone ablation therapy.

Coverage often requires a prior authorization, detailing the patient's medical history and previous treatments.

Some plans might require patients to first try alternative osteoporosis treatments before approving Prolia as a covered option.

Check your specific Anthem plan documents or contact customer service for precise details regarding coverage.

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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 Anthem

Verify Your Plan's Coverage

Start by logging into your Anthem member account online or through the Anthem mobile app to review your specific insurance plan details. This will allow you to understand if Prolia is covered, either partially or fully, under your policy.

If you do not see this information online, you can contact Anthem's customer service directly via the phone number on your insurance card to inquire about Prolia coverage and any specific requirements that may apply.

Consult with Your Healthcare Provider

Discuss with your healthcare provider about the medical necessity of Prolia for your condition. Ensure they document this necessity in your medical records, as this documentation is often required for insurance approval.

Your doctor may need to provide a prior authorization to Anthem for the Prolia treatment to be covered, which involves submitting clinical notes and justifying the need for this specific medication over others.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a Prior Authorization form to Anthem, including the necessary medical documentation and your doctor's recommendation for Prolia.

Ensure all forms are filled out correctly and completely, as missing information can delay the approval process.

Follow Up with Anthem

Regularly check the status of your Prior Authorization request either through the member portal on Anthem's website or by calling customer service.

If there are any issues or additional information required, address these promptly to avoid delays in receiving coverage for Prolia.

Appeal a Denial if Necessary

If your request for Prolia coverage is denied, review the denial letter from Anthem, which will explain the reason for the decision and the steps for submitting an appeal.

Work with your doctor to gather additional supporting documentation and submit an appeal following Anthem's guidelines.

Receive Confirmation and Proceed with Treatment

Once approved, obtain the necessary documents from Anthem, which might include a confirmation of coverage or a unique authorization number for your prescription.

Proceed to schedule your Prolia injection with your healthcare provider, ensuring that any co-pay or out-of-pocket costs are clear and manageable.

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Does Anthem Cover Prolia

Explore Anthem's Prolia coverage, ways to get approved, and costs without insurance. Plus, find answers to common Prolia questions in our detailed guide.

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Is Prolia Covered by Anthem

Does Anthem Cover Prolia?

Anthem may cover Prolia, but coverage varies based on specific plans and medical necessity criteria.

Typically, Prolia is covered for postmenopausal women with osteoporosis at high risk for fracture, men with osteoporosis at high risk for fracture, and patients with bone loss due to hormone ablation therapy.

Coverage often requires a prior authorization, detailing the patient's medical history and previous treatments.

Some plans might require patients to first try alternative osteoporosis treatments before approving Prolia as a covered option.

Check your specific Anthem plan documents or contact customer service for precise details regarding coverage.

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Anthem's Approved Criteria for Prolia Coverage

Coverage Criteria for Prolia

**Postmenopausal Osteoporosis:** Prolia is covered for the treatment of osteoporosis in postmenopausal women who have a high risk of fracture.

**Men with Osteoporosis:** Coverage is provided for men with osteoporosis who are at high risk for fracture or have a history of osteoporotic fracture.

**Glucocorticoid-Induced Osteoporosis:** Individuals receiving systemic glucocorticoid therapy for at least 3 months and who are at high risk of fractures may receive coverage for Prolia.

**Bone Health in Prostate Cancer:** Prolia is approved for men undergoing androgen deprivation therapy for nonmetastatic prostate cancer who are at high risk for fractures.

**Breast Cancer Treatment:** Coverage is provided for women receiving adjuvant aromatase inhibitor therapy for breast cancer who are at high risk for osteoporosis-related fractures.

**High Fracture Risk Assessment:** Individuals should be assessed as high risk based on a combination of factors including history of fracture, multiple risk factors for fracture, or failure or intolerance to other available osteoporosis therapy.

**Age and Clinical History:** Typically considered necessary for patients who are 50 years or older or have a documented history of osteoporotic fractures.

Why Anthem Might Deny Prolia Coverage

Reasons Anthem Might Deny Prolia Coverage

Prolia is prescribed for a condition not approved by the FDA. Anthem may require that its use is for conditions specifically listed under FDA approval.

The patient's medical history or diagnostic results do not meet Anthem's criteria for Prolia use, such as specific bone density scores or fracture history.

Prolia is requested as a first-line treatment when other therapies should be tried first, according to Anthem's guidelines.

The patient does not demonstrate documented intolerance or contraindication to other osteoporosis treatments.

The prescription does not adhere to Anthem's recommended dosage and administration frequencies.

The patient is covered under a plan that has specific exclusions or restrictions for Prolia.

Prolia is prescribed for off-label use without supporting literature or Anthem's review for the off-label indication.

Requests lack sufficient medical documentation or physician notes to justify the necessity of Prolia under Anthem's policies.

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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 Anthem

Verify Your Plan's Coverage

Start by logging into your Anthem member account online or through the Anthem mobile app to review your specific insurance plan details. This will allow you to understand if Prolia is covered, either partially or fully, under your policy.

If you do not see this information online, you can contact Anthem's customer service directly via the phone number on your insurance card to inquire about Prolia coverage and any specific requirements that may apply.

Consult with Your Healthcare Provider

Discuss with your healthcare provider about the medical necessity of Prolia for your condition. Ensure they document this necessity in your medical records, as this documentation is often required for insurance approval.

Your doctor may need to provide a prior authorization to Anthem for the Prolia treatment to be covered, which involves submitting clinical notes and justifying the need for this specific medication over others.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a Prior Authorization form to Anthem, including the necessary medical documentation and your doctor's recommendation for Prolia.

Ensure all forms are filled out correctly and completely, as missing information can delay the approval process.

Follow Up with Anthem

Regularly check the status of your Prior Authorization request either through the member portal on Anthem's website or by calling customer service.

If there are any issues or additional information required, address these promptly to avoid delays in receiving coverage for Prolia.

Appeal a Denial if Necessary

If your request for Prolia coverage is denied, review the denial letter from Anthem, which will explain the reason for the decision and the steps for submitting an appeal.

Work with your doctor to gather additional supporting documentation and submit an appeal following Anthem's guidelines.

Receive Confirmation and Proceed with Treatment

Once approved, obtain the necessary documents from Anthem, which might include a confirmation of coverage or a unique authorization number for your prescription.

Proceed to schedule your Prolia injection with your healthcare provider, ensuring that any co-pay or out-of-pocket costs are clear and manageable.

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

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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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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 Anthem Cover Prolia

Explore Anthem's Prolia coverage, ways to get approved, and costs without insurance. Plus, find answers to common Prolia questions in our detailed guide.

Achieve Your Goals Faster with Curex