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Does Blue Cross Blue Shield of Massachusetts Cover Prolia

Explore coverage for Prolia by Blue Cross Blue Shield MA. Learn why it may be denied, how to secure coverage, costs without insurance, and FAQs.

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Coverage for Prolia by BCBS Massachusetts

Blue Cross Blue Shield of Massachusetts may cover Prolia for individuals diagnosed with osteoporosis to reduce fracture risk, particularly for postmenopausal women and men with a higher fracture risk.

Prolia is generally covered under scenarios where prior treatments have been ineffective, including patients with a history of osteoporotic fracture or multiple risk factors for fracture.

Approval often requires documentation supporting the medical necessity of Prolia, such as a bone mineral density test, clinical diagnosis of osteoporosis, and previous treatment history.

Pre-authorization may be required, and coverage can be subject to the specifics of the member's health plan and benefit design.

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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 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 Blue Cross Blue Shield of Massachusetts

Contact Blue Cross Blue Shield of Massachusetts

Begin by contacting Blue Cross Blue Shield of Massachusetts customer service via the phone number on the back of your insurance card. Confirm your plan details and ask about Prolia coverage specifics.
Use the Blue Cross Blue Shield of Massachusetts website or member portal to log into your account for additional coverage information.

Verify Prolia Coverage

Inquire if Prolia is covered under your specific healthcare plan. Coverage can depend on your plan's benefits and the necessity of the medication for your condition.
Ask if pre-authorization or any documentation is needed before coverage approval. Knowing the prerequisites can expedite the process.

Consult with Your Healthcare Provider

Discuss your need for Prolia with your healthcare provider. They can often provide essential information that might be required by your insurance for coverage approval.
Request your healthcare provider to assist with pre-authorization if it’s necessary, as they must often submit clinical information and justification for the prescription.

Submit Necessary Documentation

Work with your healthcare provider to gather and submit all required documentation and prior authorization forms to Blue Cross Blue Shield of Massachusetts. This step is crucial for the approval process.
Ensure that all paperwork, including medical necessity and insurance forms, is filled out completely and correctly to avoid any delays.

Follow Up with Customer Service

After submission, regularly follow up with Blue Cross Blue Shield of Massachusetts’s customer service to check on the status of your Prolia coverage request.
Document all interactions, noting the date, time, and representative's name, for your records and future reference if needed.

Understand Financial Responsibility

Once approved, confirm what percentage of the cost will be covered by Blue Cross Blue Shield and what your out-of-pocket expenses will be, if any.
Ask about any co-payments or additional fees that might apply to Prolia to better budget for your treatment plan.

Plan for Future Appointments

Schedule your Prolia doses systematically, adhering to the ongoing treatment schedule advised by your healthcare provider.
Remain proactive in keeping Blue Cross Blue Shield of Massachusetts updated on any changes in treatment or dosage to maintain compliance with your coverage plan.

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FAQs

Does Blue Cross Blue Shield of Massachusetts Cover Prolia

Explore coverage for Prolia by Blue Cross Blue Shield MA. Learn why it may be denied, how to secure coverage, costs without insurance, and FAQs.

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Is Prolia Covered by Blue Cross Blue Shield of Massachusetts

Coverage for Prolia by BCBS Massachusetts

Blue Cross Blue Shield of Massachusetts may cover Prolia for individuals diagnosed with osteoporosis to reduce fracture risk, particularly for postmenopausal women and men with a higher fracture risk.

Prolia is generally covered under scenarios where prior treatments have been ineffective, including patients with a history of osteoporotic fracture or multiple risk factors for fracture.

Approval often requires documentation supporting the medical necessity of Prolia, such as a bone mineral density test, clinical diagnosis of osteoporosis, and previous treatment history.

Pre-authorization may be required, and coverage can be subject to the specifics of the member's health plan and benefit design.

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Blue Cross Blue Shield of Massachusetts's Approved Criteria for Prolia Coverage

Criteria for Coverage of Prolia

Prolia is covered for use in individuals diagnosed with osteoporosis who are considered at high risk for fracture. This includes individuals who have either a history of osteoporotic fracture, multiple risk factors for fracture, or those who have failed or are intolerant to other osteoporosis therapies.

Coverage is provided for postmenopausal women with osteoporosis who meet the high-risk fracture criteria.

Men with osteoporosis at high risk for fracture are also eligible for coverage under certain conditions, similar to the criteria applied to postmenopausal women.

Patients with bone loss associated with hormone ablation therapy for both breast cancer and prostate cancer may be considered for coverage when they are at a heightened risk for fracture.

Medical documentation should reflect the individual's high risk for fracture and the necessity for Prolia, reinforcing that alternative treatments are either unsuitable or have been ineffective.

The prescribing healthcare provider must demonstrate that the patient meets all required guidelines, including that Prolia is being used as part of an appropriate treatment strategy for their patient profile.

Initial coverage approval is typically for a period consistent with the prescribed treatment course, with further provisions for renewals based on demonstrated therapeutic benefit and continued eligibility under the criteria provided.

Why Blue Cross Blue Shield of Massachusetts Might Deny Prolia Coverage

Situations Where Blue Cross Blue Shield of Massachusetts Might Deny Prolia Coverage

Prolia is prescribed for a condition or diagnosis that is not FDA-approved. The insurance may deny coverage if the drug is being used off-label without proper documentation or authorization.

Failure to provide necessary documentation such as bone mineral density test results or other diagnostic information required to justify Prolia treatment.

The patient does not meet the required medical criteria, such as specific levels of osteoporosis-related risk or previous fractures, as outlined in the insurer’s medical policy.

The patient has not tried and failed other, less expensive osteoporosis treatments before considering Prolia, when a step therapy protocol is required.

Prolia is not administered according to the dosing schedule specified by the manufacturer, which may lead to questions regarding the medical necessity of the treatment being sought.

The healthcare provider or facility administering Prolia is out of network, resulting in a lack of coverage under certain insurance plans or tiers.

Prolia is categorized under an inaccessible benefit plan design or policy exclusion, including certain high deductible or catastrophic plans which may not cover specialty medications.

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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 Blue Cross Blue Shield of Massachusetts

Contact Blue Cross Blue Shield of Massachusetts

Begin by contacting Blue Cross Blue Shield of Massachusetts customer service via the phone number on the back of your insurance card. Confirm your plan details and ask about Prolia coverage specifics.
Use the Blue Cross Blue Shield of Massachusetts website or member portal to log into your account for additional coverage information.

Verify Prolia Coverage

Inquire if Prolia is covered under your specific healthcare plan. Coverage can depend on your plan's benefits and the necessity of the medication for your condition.
Ask if pre-authorization or any documentation is needed before coverage approval. Knowing the prerequisites can expedite the process.

Consult with Your Healthcare Provider

Discuss your need for Prolia with your healthcare provider. They can often provide essential information that might be required by your insurance for coverage approval.
Request your healthcare provider to assist with pre-authorization if it’s necessary, as they must often submit clinical information and justification for the prescription.

Submit Necessary Documentation

Work with your healthcare provider to gather and submit all required documentation and prior authorization forms to Blue Cross Blue Shield of Massachusetts. This step is crucial for the approval process.
Ensure that all paperwork, including medical necessity and insurance forms, is filled out completely and correctly to avoid any delays.

Follow Up with Customer Service

After submission, regularly follow up with Blue Cross Blue Shield of Massachusetts’s customer service to check on the status of your Prolia coverage request.
Document all interactions, noting the date, time, and representative's name, for your records and future reference if needed.

Understand Financial Responsibility

Once approved, confirm what percentage of the cost will be covered by Blue Cross Blue Shield and what your out-of-pocket expenses will be, if any.
Ask about any co-payments or additional fees that might apply to Prolia to better budget for your treatment plan.

Plan for Future Appointments

Schedule your Prolia doses systematically, adhering to the ongoing treatment schedule advised by your healthcare provider.
Remain proactive in keeping Blue Cross Blue Shield of Massachusetts updated on any changes in treatment or dosage to maintain compliance with your coverage plan.

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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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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.

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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 Blue Cross Blue Shield of Massachusetts Cover Prolia

Explore coverage for Prolia by Blue Cross Blue Shield MA. Learn why it may be denied, how to secure coverage, costs without insurance, and FAQs.

Achieve Your Goals Faster with Curex