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Does Blue Cross Blue Shield of Minnesota Cover Prolia

Explore coverage of Prolia by Blue Cross Blue Shield of Minnesota, reasons for denial, ways to secure coverage, costs without insurance, and common FAQs.

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Prolia Coverage by Blue Cross Blue Shield of Minnesota

Blue Cross Blue Shield of Minnesota may cover Prolia (denosumab) for patients diagnosed with osteoporosis to reduce the risk of fractures.

Coverage is typically provided for postmenopausal women and men at high risk of fracture who have either failed other osteoporosis therapies or cannot take other medications.

Prolia may also be considered for patients undergoing androgen deprivation therapy for prostate cancer or adjuvant aromatase inhibitor therapy for breast cancer, with verification of bone mass reduction.

Criteria for Coverage

A doctor’s prescription and documentation of medical necessity are required.

Pre-authorization may be necessary, confirming Prolia as a suitable treatment due to previous inadequate response or intolerance to alternative treatments.

Eligibility generally depends on your specific plan details and conditions, so it's essential to review your policy or contact Blue Cross Blue Shield of Minnesota for exact coverage information.

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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 Minnesota

Check Your Policy Benefits

Log into your Blue Cross Blue Shield of Minnesota member account online or review your policy documents to check if Prolia is covered under your plan.
Search for details on coverage for prescription drugs, particularly biologics, or osteoporosis treatments.

Consult with Your Healthcare Provider

Speak with your doctor about your need for Prolia to manage osteoporosis.
Request a detailed prescription and medical necessity letter from your provider, highlighting why Prolia is the most suitable treatment for your condition.

Prior Authorization

Contact Blue Cross Blue Shield of Minnesota to determine if prior authorization is required for Prolia.
If needed, work with your healthcare provider to complete and submit the necessary prior authorization forms.
Ensure that all supporting documents, such as your medical necessity letter, are included in the submission.

Pharmacy Benefits and Network

Verify if Prolia is covered under your pharmacy benefits by contacting the customer service of Blue Cross Blue Shield of Minnesota.
Check if there is a preferred pharmacy network where you need to fill the prescription for Prolia for it to be covered.

Appeal Process

If your initial request for Prolia coverage is denied, understand the reason for denial closely detailed in the notification from Blue Cross Blue Shield of Minnesota.
File an appeal by following the process outlined in your insurance policy documents or by contacting customer service for guidance.
Include additional documents or endorsements from your healthcare provider to strengthen your appeal where necessary.

Keep Detailed Records

Maintain records of all communications with Blue Cross Blue Shield of Minnesota, including dates, times, and the names of representatives spoken to regarding Prolia coverage.
Store all copies of submitted forms, responses, and related medical documents for reference throughout the process.

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Does Blue Cross Blue Shield of Minnesota Cover Prolia

Explore coverage of Prolia by Blue Cross Blue Shield of Minnesota, reasons for denial, ways to secure coverage, costs without insurance, and common FAQs.

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Is Prolia Covered by Blue Cross Blue Shield of Minnesota

Prolia Coverage by Blue Cross Blue Shield of Minnesota

Blue Cross Blue Shield of Minnesota may cover Prolia (denosumab) for patients diagnosed with osteoporosis to reduce the risk of fractures.

Coverage is typically provided for postmenopausal women and men at high risk of fracture who have either failed other osteoporosis therapies or cannot take other medications.

Prolia may also be considered for patients undergoing androgen deprivation therapy for prostate cancer or adjuvant aromatase inhibitor therapy for breast cancer, with verification of bone mass reduction.

Criteria for Coverage

A doctor’s prescription and documentation of medical necessity are required.

Pre-authorization may be necessary, confirming Prolia as a suitable treatment due to previous inadequate response or intolerance to alternative treatments.

Eligibility generally depends on your specific plan details and conditions, so it's essential to review your policy or contact Blue Cross Blue Shield of Minnesota for exact coverage information.

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

Eligibility for Prolia Coverage

Patient must be diagnosed with osteoporosis confirmed by a bone mineral density (BMD) test or have a history of osteoporotic fracture. Documentation of BMD scores must be provided.

Prolia is covered for postmenopausal women or men at high risk for fracture, where other osteoporosis therapies are either ineffective or inappropriate.

Patients should have failed a trial of oral bisphosphonates, unless contraindicated or demonstrated intolerance to bisphosphonates.

The patient must not have any uncorrected pre-existing hypocalcemia, and calcium and vitamin D supplementation should be initiated if necessary.

Medical Necessity Guidelines

Documentation must show a high risk for fracture. This includes recurrent fractures while on other osteoporosis treatments or BMD scores indicative of increased fracture risk.

Prolia is covered for patients undergoing systemic glucocorticoid therapy (defined as ≥7.5 mg/day of prednisone or equivalent) for a minimum of 6 months.

There must be clinical evidence or patient history that supports the need for treatment with Prolia over alternative osteoporosis treatments.

Administration Requirements

Prolia must be administered by a healthcare professional with proper certification and training.

Coverage is for the FDA-approved dosage of 60 mg every six months; no more frequent reimbursement will be approved without further medical justification.

Prolia administrations should be timed and documented in patient health records to ensure appropriate intervals between doses.

Renewal Criteria

Continuing Prolia treatment will require demonstrated treatment efficacy, as evidenced by stabilization or improvement in BMD or fracture risk reduction.

Renewal authorization requires submission of up-to-date medical records, including recent BMD tests and a review of any adverse effects experienced by the patient.

Patient compliance with follow-up appointments and prescribed supplementation must be documented to continue coverage.

Why Blue Cross Blue Shield of Minnesota Might Deny Prolia Coverage

Situations Where Prolia Coverage is Denied by Blue Cross Blue Shield of Minnesota

Patients who do not meet the criteria for osteoporosis but are seeking Prolia for other bone conditions without sufficient medical justification.

Requests for Prolia to be used as the first-line treatment without prior trials of other recommended osteoporosis treatments, such as bisphosphonates.

Instances where Prolia is being requested for off-label use that lacks substantial clinical evidence or FDA approval.

Denials may occur if there is inadequate documentation to demonstrate a sufficient risk of fracture, as required by policy guidelines.

Requests from patients who have contraindications to Prolia, such as hypocalcemia or existing hypersensitivity to denosumab.

If Prolia is prescribed for patients with reversible causes of osteoporosis where alternative treatments are deemed more appropriate.

Situations where the Prolia prescription exceeds the recommended dosing intervals without justified medical necessity.

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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 Minnesota

Check Your Policy Benefits

Log into your Blue Cross Blue Shield of Minnesota member account online or review your policy documents to check if Prolia is covered under your plan.
Search for details on coverage for prescription drugs, particularly biologics, or osteoporosis treatments.

Consult with Your Healthcare Provider

Speak with your doctor about your need for Prolia to manage osteoporosis.
Request a detailed prescription and medical necessity letter from your provider, highlighting why Prolia is the most suitable treatment for your condition.

Prior Authorization

Contact Blue Cross Blue Shield of Minnesota to determine if prior authorization is required for Prolia.
If needed, work with your healthcare provider to complete and submit the necessary prior authorization forms.
Ensure that all supporting documents, such as your medical necessity letter, are included in the submission.

Pharmacy Benefits and Network

Verify if Prolia is covered under your pharmacy benefits by contacting the customer service of Blue Cross Blue Shield of Minnesota.
Check if there is a preferred pharmacy network where you need to fill the prescription for Prolia for it to be covered.

Appeal Process

If your initial request for Prolia coverage is denied, understand the reason for denial closely detailed in the notification from Blue Cross Blue Shield of Minnesota.
File an appeal by following the process outlined in your insurance policy documents or by contacting customer service for guidance.
Include additional documents or endorsements from your healthcare provider to strengthen your appeal where necessary.

Keep Detailed Records

Maintain records of all communications with Blue Cross Blue Shield of Minnesota, including dates, times, and the names of representatives spoken to regarding Prolia coverage.
Store all copies of submitted forms, responses, and related medical documents for reference throughout the process.

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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 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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Can I pay with an FSA or HSA card?

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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 Minnesota Cover Prolia

Explore coverage of Prolia by Blue Cross Blue Shield of Minnesota, reasons for denial, ways to secure coverage, costs without insurance, and common FAQs.

Achieve Your Goals Faster with Curex