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Does Blue Cross Blue Shield of North Carolina Cover Prolia

Explore Prolia coverage with Blue Cross Blue Shield of North Carolina, reasons for denial, costs without insurance, and FAQs for informed decisions.

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Coverage for Prolia

Blue Cross Blue Shield of North Carolina typically covers Prolia for patients diagnosed with osteoporosis due to menopause or certain other health conditions where there is an increased risk of fracture.

Coverage generally applies if Prolia is prescribed after other treatments are deemed unsuitable or ineffective for the patient.

Criteria for Coverage

Patient must have a documented diagnosis of osteoporosis with significant fracture risk or history of fractures.

A healthcare professional must confirm that alternative osteoporosis treatments are ineffective or contraindicated.

Pre-authorization from Blue Cross Blue Shield of North Carolina might be required before initiating Prolia treatment.

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How to Get Prolia Coverage with Blue Cross Blue Shield of North Carolina

Verify Coverage with Your Plan

Contact Blue Cross Blue Shield of North Carolina (BCBSNC) by calling the customer service number on your insurance card to verify if Prolia is covered under your specific plan.

Check the BCBSNC member portal online for any specific details regarding your pharmaceutical benefits plan. This can often include a formulary list that specifies if Prolia is covered.

Confirm whether Prolia requires prior authorization or if there are any specific requirements such as step therapy or quantity limitations.

Consult with Your Healthcare Provider

Discuss with your healthcare provider about your need for Prolia and get their professional input on its medical necessity.

Have your healthcare provider prepare necessary medical documentation to support the need for Prolia, including medical history and any other pertinent information.

Obtain and Submit Prior Authorization

If prior authorization is required, ask your healthcare provider to initiate this process. This often involves filling out a prior authorization form detailing the medical necessity.

Submit the completed prior authorization form to BCBSNC. Your healthcare provider's office may handle this for you, but ensure it is sent in a timely manner.

Follow up with BCBSNC to confirm receipt and obtain confirmation of whether the authorization is approved.

Explore Financial Assistance Programs

If coverage is denied or you face high out-of-pocket costs, inquire about patient assistance programs offered by the manufacturer of Prolia.

Look into state or national assistance programs for additional support if needed.

Appeal Denied Coverage

If your request for coverage of Prolia is denied, ask BCBSNC for detailed information regarding the denial reason.

Work with your healthcare provider to gather additional supporting documentation to make an appeal.

Submit an appeal to BCBSNC within the timeframe outlined in their denial letter, ensuring to include all relevant medical documentation and any new evidence supporting the necessity for Prolia.

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FAQs

Does Blue Cross Blue Shield of North Carolina Cover Prolia

Explore Prolia coverage with Blue Cross Blue Shield of North Carolina, reasons for denial, costs without insurance, and FAQs for informed decisions.

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Is Prolia Covered by Blue Cross Blue Shield of North Carolina

Coverage for Prolia

Blue Cross Blue Shield of North Carolina typically covers Prolia for patients diagnosed with osteoporosis due to menopause or certain other health conditions where there is an increased risk of fracture.

Coverage generally applies if Prolia is prescribed after other treatments are deemed unsuitable or ineffective for the patient.

Criteria for Coverage

Patient must have a documented diagnosis of osteoporosis with significant fracture risk or history of fractures.

A healthcare professional must confirm that alternative osteoporosis treatments are ineffective or contraindicated.

Pre-authorization from Blue Cross Blue Shield of North Carolina might be required before initiating Prolia treatment.

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Blue Cross Blue Shield of North Carolina's Approved Criteria for Prolia Coverage

Eligibility Criteria for Prolia Coverage

Patients must have a diagnosis of osteoporosis in postmenopausal women at high risk for fracture, defined as having a history of osteoporotic fracture or multiple risk factors for fracture.

Coverage is available for men with osteoporosis who are at high risk for fracture, as evidenced by a history of osteoporotic fracture or multiple risk factors for fracture.

Individuals who require treatment due to failure or contraindication of other osteoporosis therapies, as documented by previous medical records.

Verification of bone mineral density (BMD) testing results indicating osteoporosis, typically defined as a T-score of -2.5 or lower on the BMD scan.

Patients with severe renal impairment or individuals unable to tolerate oral bisphosphonates due to documented adverse effects.

Documentation Requirements

A completed prior authorization request form by the prescribing healthcare provider, detailing the clinical need and justification for Prolia treatment.

Submission of recent medical history and BMD results supporting the diagnosis and patient’s risk factors for fractures.

Records of previous osteoporosis treatments, including reasons for discontinuation if applicable.

Additional Considerations

Coverage may be applicable under special circumstances for patients receiving concomitant glucocorticoid therapy, which increases the risk for osteoporosis and fractures.

Patients who are receiving treatment for cancer and at risk for bone loss as a result of treatment may be eligible, provided specific therapy aligns with clinical guidelines.

The healthcare provider’s attestation to the patient's education on potential Prolia side effects and the need for regular follow-ups during treatment.

Why Blue Cross Blue Shield of North Carolina Might Deny Prolia Coverage

Situations When Prolia is Not Covered by Blue Cross Blue Shield of North Carolina

The patient does not meet the clinical criteria specified for osteoporosis treatment. This includes insufficient evidence of high fracture risk or lack of specific bone density test results.

Prolia is requested for off-label use or for conditions not approved by the FDA. This includes any use other than for the prevention of fractures in patients with osteoporosis.

Prolia is intended for administration outside the approved healthcare settings, such as a home setting, without proper medical supervision.

The patient has not undergone prior therapies or treatments required as preconditions before using Prolia, like the lack of treatment with bisphosphonates in certain cases.

A request for Prolia exceeds the established dosing frequency, such as more frequent dosing than every six months, which falls outside the standard coverage guidelines.

There is any evidence of hypersensitivity or previous adverse reactions to denosumab or any component of Prolia.

Prolia is prescribed to individuals with non-resolving hypocalcemia or low calcium levels that could not be adequately managed prior to administration.

The patient is utilizing Prolia concomitantly with other medications contraindicated for use with Prolia, and no compelling justification is provided.

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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 North Carolina

Verify Coverage with Your Plan

Contact Blue Cross Blue Shield of North Carolina (BCBSNC) by calling the customer service number on your insurance card to verify if Prolia is covered under your specific plan.

Check the BCBSNC member portal online for any specific details regarding your pharmaceutical benefits plan. This can often include a formulary list that specifies if Prolia is covered.

Confirm whether Prolia requires prior authorization or if there are any specific requirements such as step therapy or quantity limitations.

Consult with Your Healthcare Provider

Discuss with your healthcare provider about your need for Prolia and get their professional input on its medical necessity.

Have your healthcare provider prepare necessary medical documentation to support the need for Prolia, including medical history and any other pertinent information.

Obtain and Submit Prior Authorization

If prior authorization is required, ask your healthcare provider to initiate this process. This often involves filling out a prior authorization form detailing the medical necessity.

Submit the completed prior authorization form to BCBSNC. Your healthcare provider's office may handle this for you, but ensure it is sent in a timely manner.

Follow up with BCBSNC to confirm receipt and obtain confirmation of whether the authorization is approved.

Explore Financial Assistance Programs

If coverage is denied or you face high out-of-pocket costs, inquire about patient assistance programs offered by the manufacturer of Prolia.

Look into state or national assistance programs for additional support if needed.

Appeal Denied Coverage

If your request for coverage of Prolia is denied, ask BCBSNC for detailed information regarding the denial reason.

Work with your healthcare provider to gather additional supporting documentation to make an appeal.

Submit an appeal to BCBSNC within the timeframe outlined in their denial letter, ensuring to include all relevant medical documentation and any new evidence supporting the necessity for Prolia.

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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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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.

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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.

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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 North Carolina Cover Prolia

Explore Prolia coverage with Blue Cross Blue Shield of North Carolina, reasons for denial, costs without insurance, and FAQs for informed decisions.

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