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Does Blue Shield of California Cover Prolia

Find out if Blue Shield covers Prolia, explore reasons for denials, learn how to secure coverage, understand costs without insurance, and get your FAQs answered.

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Coverage for Prolia by Blue Shield of California

Blue Shield of California may cover Prolia under medical benefits for patients who meet specific medical criteria. It is primarily covered for conditions like osteoporosis in postmenopausal women or men at high fracture risk.

Criteria often include a history of fractures or a failure of other osteoporosis treatments. Prior authorization might be required to ensure coverage.

Patients typically need to provide medical documentation from their healthcare provider demonstrating the necessity of Prolia.

It's essential to check the specific plan details, as coverage can vary based on individual policy requirements and plan benefits.

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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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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 Shield of California

Contact Member Services

Call the Blue Shield of California Member Services number on your insurance card to inquire about Prolia coverage.

Confirm whether Prolia is included in your plan's prescription drug coverage or if it's covered under medical benefits.

Ask if prior authorization is required for Prolia and the steps involved in obtaining it.

Consult with Your Healthcare Provider

Discuss with your doctor the medical necessity of using Prolia for your condition.

Ensure your healthcare provider is aware of Blue Shield of California's requirements and paperwork involved in securing coverage.

Request any necessary documentation and medical records that may be needed to support the prior authorization request.

Submit Prior Authorization Request

Work with your healthcare provider to complete all necessary forms and documentation for a prior authorization request.

Submit the completed request to Blue Shield of California through the preferred method (online, fax, or mail).

Follow up with both your healthcare provider and Blue Shield to ensure the request has been received and is under review.

Understand the Appeal Process

If your prior authorization is denied, review the denial letter for specific reasons and understand the next steps for appeal.

Work with your healthcare provider to gather any additional information or justification needed to support your appeal.

Submit the appeal following Blue Shield's guidelines and timelines, and keep track of all communications and documents.

Review Your Benefits and Costs

Examine your plan’s specifics related to copayments, coinsurance, and deductibles that may apply to Prolia.

Contact Blue Shield of California if you have any questions or concerns regarding out-of-pocket expenses once coverage is approved.

Consider discussing financial assistance options with your healthcare provider or the manufacturer of Prolia if costs remain high.

Utilize Online Member Resources

Log in to your Blue Shield of California online member account to access resources related to prescription drug coverage.

Utilize the online chat feature or secure messaging for quick questions and updates regarding your Prolia coverage request.

Download or review policy documents related to prescription drug coverage for a comprehensive understanding of your benefits.

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FAQs

Does Blue Shield of California Cover Prolia

Find out if Blue Shield covers Prolia, explore reasons for denials, learn how to secure coverage, understand costs without insurance, and get your FAQs answered.

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Is Prolia Covered by Blue Shield of California

Coverage for Prolia by Blue Shield of California

Blue Shield of California may cover Prolia under medical benefits for patients who meet specific medical criteria. It is primarily covered for conditions like osteoporosis in postmenopausal women or men at high fracture risk.

Criteria often include a history of fractures or a failure of other osteoporosis treatments. Prior authorization might be required to ensure coverage.

Patients typically need to provide medical documentation from their healthcare provider demonstrating the necessity of Prolia.

It's essential to check the specific plan details, as coverage can vary based on individual policy requirements and plan benefits.

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Blue Shield of California's Approved Criteria for Prolia Coverage

Prolia Coverage Criteria

Prolia is approved for postmenopausal women with osteoporosis at high risk for fracture.

Candidates must have a history of osteoporotic fractures or multiple risk factors for fracture.

Prolia may be covered for patients who have failed or are intolerant to other osteoporosis therapies.

Men with osteoporosis at high risk for fracture are eligible for Prolia coverage under defined criteria similar to those for postmenopausal women.

Patients with glucocorticoid-induced osteoporosis are considered for coverage if they have high fracture risk.

Prolia may be approved for individuals undergoing androgen deprivation therapy for non-metastatic prostate cancer with high risk for fracture.

Premenopausal women with breast cancer receiving adjuvant aromatase inhibitor therapy at high risk for fractures may be eligible for coverage.

Why Blue Shield of California Might Deny Prolia Coverage

Situations Where Blue Shield of California Might Deny Prolia Coverage

**Non-FDA Approved Usages:** Prolia is only approved by the FDA for specific conditions such as osteoporosis in postmenopausal women and certain cases of bone loss. Any request for Prolia for conditions not FDA-approved would likely be denied by Blue Shield of California.

**Lack of Medical Necessity:** If the patient does not meet the medical necessity criteria as defined by Blue Shield of California, the coverage for Prolia may be denied. This might include situations where other treatments have not been attempted or documented.

**Incorrect Diagnosis Codes:** Use of incorrect or non-specific diagnosis codes associated with the request for Prolia can result in denial of coverage. Blue Shield requires precise coding to match the approved uses of the medication.

**Lack of Prior Authorization:** If Prolia is prescribed without obtaining the necessary prior authorization from Blue Shield of California, the claim is likely to be denied. Prior authorization is often a prerequisite for coverage.

**Non-Compliance with Treatment Protocol:** For patients who do not comply with recommended treatment protocols or follow-up requirements when using Prolia, Blue Shield may deny further coverage. Documentation of compliance is essential.

**Duplicate Therapy:** Coverage can be denied if Prolia is part of a duplicate therapy regimen where the patient is receiving another biologic treatment for the same condition.

**Exceeding Approved Dosing Frequency:** If Prolia is administered more frequently than the approved dosing schedule without specific justification, Blue Shield may deny coverage for these additional doses.

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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 Shield of California

Contact Member Services

Call the Blue Shield of California Member Services number on your insurance card to inquire about Prolia coverage.

Confirm whether Prolia is included in your plan's prescription drug coverage or if it's covered under medical benefits.

Ask if prior authorization is required for Prolia and the steps involved in obtaining it.

Consult with Your Healthcare Provider

Discuss with your doctor the medical necessity of using Prolia for your condition.

Ensure your healthcare provider is aware of Blue Shield of California's requirements and paperwork involved in securing coverage.

Request any necessary documentation and medical records that may be needed to support the prior authorization request.

Submit Prior Authorization Request

Work with your healthcare provider to complete all necessary forms and documentation for a prior authorization request.

Submit the completed request to Blue Shield of California through the preferred method (online, fax, or mail).

Follow up with both your healthcare provider and Blue Shield to ensure the request has been received and is under review.

Understand the Appeal Process

If your prior authorization is denied, review the denial letter for specific reasons and understand the next steps for appeal.

Work with your healthcare provider to gather any additional information or justification needed to support your appeal.

Submit the appeal following Blue Shield's guidelines and timelines, and keep track of all communications and documents.

Review Your Benefits and Costs

Examine your plan’s specifics related to copayments, coinsurance, and deductibles that may apply to Prolia.

Contact Blue Shield of California if you have any questions or concerns regarding out-of-pocket expenses once coverage is approved.

Consider discussing financial assistance options with your healthcare provider or the manufacturer of Prolia if costs remain high.

Utilize Online Member Resources

Log in to your Blue Shield of California online member account to access resources related to prescription drug coverage.

Utilize the online chat feature or secure messaging for quick questions and updates regarding your Prolia coverage request.

Download or review policy documents related to prescription drug coverage for a comprehensive understanding of your benefits.

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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 Blue Shield of California Cover Prolia

Find out if Blue Shield covers Prolia, explore reasons for denials, learn how to secure coverage, understand costs without insurance, and get your FAQs answered.

Achieve Your Goals Faster with Curex