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Does Centene Corporation Cover Prolia

Explore Centene Corporation's Prolia coverage, possible denial reasons, obtaining coverage tips, cost without insurance, and FAQs for informed decisions.

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Does Centene Corporation Cover Prolia?

Centene Corporation may cover Prolia for patients who meet specific medical criteria. Coverage typically includes treatment for osteoporosis in postmenopausal women at high risk of fracture or who have had prior fractures.

Prolia may also be covered for men with osteoporosis at high risk of fracture or those who have experienced treatment failure with other osteoporosis therapies.

Eligibility may require documented evidence of bone density tests and, if applicable, a history of fracture.

Patients often need prior authorization from Centene to confirm Prolia coverage, ensuring that they meet all specified criteria.

It's crucial for patients to consult with their healthcare provider and Centene for precise coverage details and to complete any necessary forms.

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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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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 has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

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 Centene Corporation

Research Centene's Health Plans

Visit Centene Corporation’s official website to understand the health insurance products they offer, including any Medicare, Medicaid, or individual health plans.

Use the “Find a Plan” feature if available to search for plans that are known to cover Prolia. This can provide an overview of available options.

Contact Centene Customer Service

Once you've identified potential plans, call Centene Corporation’s customer service for detailed information. They can confirm Prolia coverage specifics, any necessary prerequisites, and whether coverage varies between different plans.

Prepare a list of questions or concerns about Prolia coverage. Clarifying what’s covered, out-of-pocket costs, and any prior authorization requirements can save you future hassle.

Check Plan Details

Carefully review plan summaries and coverage documents, which are usually available online or can be emailed by customer service. Look for information about "pharmacy benefits" or "drug coverage" regarding Prolia.

Identify any mention of Prolia under “Specialty Medications” or equivalent sections, since it’s a medication often requiring special handling.

Verify Network and Requirements

Ensure that your healthcare provider and pharmacy are in-network to avoid unexpected expenses when accessing Prolia under Centene’s plans.

Ask if there are specific steps required, such as prior authorizations, step therapy, or specific forms. Knowing these can ensure that you meet necessary requirements before initiating treatment.

Apply for a Health Plan

Once you have selected a plan that covers Prolia, proceed with the application process during an open enrollment period. Ensure that all information is accurate to avoid processing delays.

Contact a health insurance broker or agent if needed, for assistance with application completion and to better understand plan benefits specific to Prolia.

Follow Up

After applying, follow up with Centene to confirm your application status and ensure that all requirements for Prolia coverage are in place.

Request confirmation of coverage that specifically mentions Prolia, which can be useful for resolving any discrepancies later.

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FAQs

Does Centene Corporation Cover Prolia

Explore Centene Corporation's Prolia coverage, possible denial reasons, obtaining coverage tips, cost without insurance, and FAQs for informed decisions.

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Is Prolia Covered by Centene Corporation

Does Centene Corporation Cover Prolia?

Centene Corporation may cover Prolia for patients who meet specific medical criteria. Coverage typically includes treatment for osteoporosis in postmenopausal women at high risk of fracture or who have had prior fractures.

Prolia may also be covered for men with osteoporosis at high risk of fracture or those who have experienced treatment failure with other osteoporosis therapies.

Eligibility may require documented evidence of bone density tests and, if applicable, a history of fracture.

Patients often need prior authorization from Centene to confirm Prolia coverage, ensuring that they meet all specified criteria.

It's crucial for patients to consult with their healthcare provider and Centene for precise coverage details and to complete any necessary forms.

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Centene Corporation's Approved Criteria for Prolia Coverage

Criteria for Prolia Coverage under Centene Corporation

**Osteoporosis in Postmenopausal Women**: Coverage includes women who are postmenopausal and are at a high risk of fracture, as confirmed by a bone density test or a history of prior osteoporotic fractures.

**Osteoporosis in Men**: Men with a high risk of fracture, particularly with a demonstrated history of osteoporotic fractures, are eligible for Prolia coverage.

**Glucocorticoid-Induced Osteoporosis**: Patients who have been receiving glucocorticoids for at least 6 months and are at high risk of fracture are covered.

**Bone Loss in Patients with Aromatase Inhibitor Therapy for Breast Cancer**: Women who have developed significant bone loss due to long-term aromatase inhibitor therapy for breast cancer are covered for Prolia treatment.

**Bone Loss in Patients with Androgen Deprivation Therapy for Prostate Cancer**: Men undergoing androgen deprivation therapy for prostate cancer, who are at increased risk of fractures, are eligible.

**Prior Failed Adequate Trial**: Coverage may be provided for patients who have failed an adequate trial of other osteoporosis treatments, such as bisphosphonates, due to lack of efficacy or adverse reactions.

**Provider Prescription**: Prolia must be prescribed by a licensed healthcare provider specializing in conditions treated by Prolia to receive coverage.

**Verification of Medical Necessity**: Insurance coverage is contingent upon proper documentation and verification of medical necessity by a healthcare professional.

Why Centene Corporation Might Deny Prolia Coverage

Situations Where Centene Corporation Might Deny Prolia Coverage

Prolia is requested for indications not approved by the FDA. Such off-label uses are not included in Centene Corporation's coverage policy.

The patient does not meet established clinical criteria, such as having a bone mineral density score that falls outside the specified range set by Centene.

Requests for Prolia are made without prior authorization. Centene requires a prior authorization to ensure medical necessity and appropriateness.

The patient is not enrolled in a plan that includes the pharmacy benefit covering biologic medications like Prolia.

No documentation is provided to support diagnosis or demonstrate the need for Prolia as a treatment, resulting in insufficient evidence for coverage determination.

Prolia is being requested for a duration or frequency not aligned with medically accepted guidelines or Centene policy limitations.

Prolia is requested when the patient has previously demonstrated intolerance or adverse reactions to the medication without exhausting alternative treatments.

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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 Centene Corporation

Research Centene's Health Plans

Visit Centene Corporation’s official website to understand the health insurance products they offer, including any Medicare, Medicaid, or individual health plans.

Use the “Find a Plan” feature if available to search for plans that are known to cover Prolia. This can provide an overview of available options.

Contact Centene Customer Service

Once you've identified potential plans, call Centene Corporation’s customer service for detailed information. They can confirm Prolia coverage specifics, any necessary prerequisites, and whether coverage varies between different plans.

Prepare a list of questions or concerns about Prolia coverage. Clarifying what’s covered, out-of-pocket costs, and any prior authorization requirements can save you future hassle.

Check Plan Details

Carefully review plan summaries and coverage documents, which are usually available online or can be emailed by customer service. Look for information about "pharmacy benefits" or "drug coverage" regarding Prolia.

Identify any mention of Prolia under “Specialty Medications” or equivalent sections, since it’s a medication often requiring special handling.

Verify Network and Requirements

Ensure that your healthcare provider and pharmacy are in-network to avoid unexpected expenses when accessing Prolia under Centene’s plans.

Ask if there are specific steps required, such as prior authorizations, step therapy, or specific forms. Knowing these can ensure that you meet necessary requirements before initiating treatment.

Apply for a Health Plan

Once you have selected a plan that covers Prolia, proceed with the application process during an open enrollment period. Ensure that all information is accurate to avoid processing delays.

Contact a health insurance broker or agent if needed, for assistance with application completion and to better understand plan benefits specific to Prolia.

Follow Up

After applying, follow up with Centene to confirm your application status and ensure that all requirements for Prolia coverage are in place.

Request confirmation of coverage that specifically mentions Prolia, which can be useful for resolving any discrepancies later.

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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.

Got questions? We have answers.

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 Centene Corporation Cover Prolia

Explore Centene Corporation's Prolia coverage, possible denial reasons, obtaining coverage tips, cost without insurance, and FAQs for informed decisions.

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