Does EmblemHealth Cover Prolia

Explore EmblemHealth's Prolia coverage, reasons for denial, cost without insurance, and FAQs. Learn how to obtain Prolia with your plan.
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“Curex is changing the landscape of allergies in 2024”
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Does EmblemHealth Cover Prolia?

 

  • EmblemHealth may cover Prolia for osteoporosis treatment if deemed medically necessary.
  • Coverage usually applies to patients with postmenopausal osteoporosis at high fracture risk.
  • The criteria include prior treatment failures with other osteoporosis therapies.

 

Basic Rules and Criteria

 

  • A physician's prescription and prior authorization are typically required.
  • Documentation must support medical necessity, including a diagnosis and previous treatment history.

 

Additional Considerations

 

  • Policy details may vary; members should verify with EmblemHealth directly.
  • Check for any updates to insurance plans that might affect coverage terms.

 

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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

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.

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

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 EmblemHealth

 

Verify Eligibility

 

  • Begin by reviewing your current health insurance policy with EmblemHealth to determine if Prolia (denosumab) is included in your plan's formulary. This information can typically be found on the EmblemHealth website or by contacting their customer service.
  •  

  • Ensure that you meet the necessary medical criteria for Prolia as specified by your EmblemHealth plan. This may include the diagnosis of osteoporosis or other conditions for which Prolia is indicated.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the necessity of Prolia for your treatment. Your provider can assess your condition and determine if Prolia is the right medication for you.
  •  

  • Ask your healthcare provider to assist with the documentation that may be required by EmblemHealth, such as a letter of medical necessity or prior authorization requests.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to complete and submit a prior authorization request to EmblemHealth. This is often necessary for medications like Prolia to ensure that the treatment is medically necessary and covered by your plan.
  •  

  • Ensure that all required forms and supplementary documentation are thoroughly completed and submitted as specified by EmblemHealth procedures.

 

Contact EmblemHealth Member Services

 

  • Reach out to EmblemHealth member services or utilize their online portal to confirm receipt of the prior authorization request and to verify the status of your coverage inquiry.
  •  

  • Keep a record of all correspondence and reference numbers provided during your interactions with EmblemHealth for future reference.

 

Follow Up on Authorization Status

 

  • Monitor the status of your prior authorization request with EmblemHealth. It may take several days to weeks for them to process and review your information.
  •  

  • Contact EmblemHealth if there are delays or additional information is requested to expedite the authorization process.

 

Receive and Administer Prolia

 

  • Once your prior authorization is approved, coordinate with your healthcare provider to have Prolia administered according to the advised schedule.
  •  

  • Verify any copayment or coinsurance that may apply with EmblemHealth to plan for any out-of-pocket expenses.
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Does EmblemHealth Cover Prolia

Explore EmblemHealth's Prolia coverage, reasons for denial, cost without insurance, and FAQs. Learn how to obtain Prolia with your plan.
Curex allergy drops unboxing

Is Prolia Covered by EmblemHealth

 

Does EmblemHealth Cover Prolia?

 

  • EmblemHealth may cover Prolia for osteoporosis treatment if deemed medically necessary.
  • Coverage usually applies to patients with postmenopausal osteoporosis at high fracture risk.
  • The criteria include prior treatment failures with other osteoporosis therapies.

 

Basic Rules and Criteria

 

  • A physician's prescription and prior authorization are typically required.
  • Documentation must support medical necessity, including a diagnosis and previous treatment history.

 

Additional Considerations

 

  • Policy details may vary; members should verify with EmblemHealth directly.
  • Check for any updates to insurance plans that might affect coverage terms.

 

A weight management program tailored to you

Start with Curex

EmblemHealth's Approved Criteria for Prolia Coverage

 

Prolia Coverage Criteria

 

  • EmblemHealth covers Prolia for patients meeting the criteria of diagnosis with osteoporosis in postmenopausal women at high risk of fracture.
  •  

  • Coverage is provided for individuals with a history of osteoporotic fracture or multiple risk factors for fracture.
  •  

  • Patients who have failed or are intolerant to other available osteoporosis therapies are eligible for coverage.
  •  

  • Individuals with a documented densitometric diagnosis reflecting a T-score ≤ -2.5 are also covered.
  •  

  • Prolia is covered for men with osteoporosis at high risk for fracture.
  •  

  • Coverage applies for patients undergoing androgen deprivation therapy for non-metastatic prostate cancer with high fracture risk.
  •  

  • Women receiving adjuvant aromatase inhibitor therapy for breast cancer also qualify when they are at increased risk of fracture.
  •  

  • Prolia coverage is approved for patients undergoing glucocorticoid therapy, elevating their risk of fractures.

 

Why EmblemHealth Might Deny Prolia Coverage

 

Non-Medically Necessary Uses

 

  • Prolia is not covered for uses considered as non-medically necessary. Situations where Prolia is prescribed outside of FDA-approved indications might be denied.

 

Experimental or Investigational Use

 

  • If Prolia is used for conditions that are deemed experimental or investigational, EmblemHealth may not provide coverage. This typically applies to off-label uses that lack sufficient evidence of efficacy.

 

Lack of Documentation

 

  • Claims may be denied if there is insufficient documentation to justify the medical necessity of Prolia. Detailed medical records and history of osteoporosis or related conditions are required for approval.

 

Not Meeting Clinical Criteria

 

  • EmblemHealth requires that certain clinical criteria be met for Prolia coverage. Denial may occur if these specific criteria are not sufficiently met according to their policy guidelines.

 

Plan Exclusions and Limitations

 

  • Certain health plans may have specific exclusions regarding the coverage of Prolia. Review of the individual's benefit plan is necessary to determine specific exclusions or limitations.

 

Duplicate Therapy

 

  • If Prolia is prescribed in conjunction with other osteoporosis treatments without a clear clinical indication, it may be considered duplicate therapy and not eligible for coverage.

 

Together with our partners we have changed the lives of over 300,000 patients.

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.

 

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

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.

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

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 EmblemHealth

 

Verify Eligibility

 

  • Begin by reviewing your current health insurance policy with EmblemHealth to determine if Prolia (denosumab) is included in your plan's formulary. This information can typically be found on the EmblemHealth website or by contacting their customer service.
  •  

  • Ensure that you meet the necessary medical criteria for Prolia as specified by your EmblemHealth plan. This may include the diagnosis of osteoporosis or other conditions for which Prolia is indicated.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the necessity of Prolia for your treatment. Your provider can assess your condition and determine if Prolia is the right medication for you.
  •  

  • Ask your healthcare provider to assist with the documentation that may be required by EmblemHealth, such as a letter of medical necessity or prior authorization requests.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to complete and submit a prior authorization request to EmblemHealth. This is often necessary for medications like Prolia to ensure that the treatment is medically necessary and covered by your plan.
  •  

  • Ensure that all required forms and supplementary documentation are thoroughly completed and submitted as specified by EmblemHealth procedures.

 

Contact EmblemHealth Member Services

 

  • Reach out to EmblemHealth member services or utilize their online portal to confirm receipt of the prior authorization request and to verify the status of your coverage inquiry.
  •  

  • Keep a record of all correspondence and reference numbers provided during your interactions with EmblemHealth for future reference.

 

Follow Up on Authorization Status

 

  • Monitor the status of your prior authorization request with EmblemHealth. It may take several days to weeks for them to process and review your information.
  •  

  • Contact EmblemHealth if there are delays or additional information is requested to expedite the authorization process.

 

Receive and Administer Prolia

 

  • Once your prior authorization is approved, coordinate with your healthcare provider to have Prolia administered according to the advised schedule.
  •  

  • Verify any copayment or coinsurance that may apply with EmblemHealth to plan for any out-of-pocket expenses.

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

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.
  •  

 

Have questions left?

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Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
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Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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 EmblemHealth Cover Prolia

Explore EmblemHealth's Prolia coverage, reasons for denial, cost without insurance, and FAQs. Learn how to obtain Prolia with your plan.
Curex allergy drops unboxing

Does EmblemHealth Cover Prolia

 

Does EmblemHealth Cover Prolia?

 

  • EmblemHealth may cover Prolia for osteoporosis treatment if deemed medically necessary.
  • Coverage usually applies to patients with postmenopausal osteoporosis at high fracture risk.
  • The criteria include prior treatment failures with other osteoporosis therapies.

 

Basic Rules and Criteria

 

  • A physician's prescription and prior authorization are typically required.
  • Documentation must support medical necessity, including a diagnosis and previous treatment history.

 

Additional Considerations

 

  • Policy details may vary; members should verify with EmblemHealth directly.
  • Check for any updates to insurance plans that might affect coverage terms.

 

A weight management program tailored to you

Start with Curex

Why EmblemHealth Might Deny Prolia Coverage

 

Prolia Coverage Criteria

 

  • EmblemHealth covers Prolia for patients meeting the criteria of diagnosis with osteoporosis in postmenopausal women at high risk of fracture.
  •  

  • Coverage is provided for individuals with a history of osteoporotic fracture or multiple risk factors for fracture.
  •  

  • Patients who have failed or are intolerant to other available osteoporosis therapies are eligible for coverage.
  •  

  • Individuals with a documented densitometric diagnosis reflecting a T-score ≤ -2.5 are also covered.
  •  

  • Prolia is covered for men with osteoporosis at high risk for fracture.
  •  

  • Coverage applies for patients undergoing androgen deprivation therapy for non-metastatic prostate cancer with high fracture risk.
  •  

  • Women receiving adjuvant aromatase inhibitor therapy for breast cancer also qualify when they are at increased risk of fracture.
  •  

  • Prolia coverage is approved for patients undergoing glucocorticoid therapy, elevating their risk of fractures.

 

Together with our partners we have changed the lives of over 300,000 patients.

Prolia FAQ

 

Non-Medically Necessary Uses

 

  • Prolia is not covered for uses considered as non-medically necessary. Situations where Prolia is prescribed outside of FDA-approved indications might be denied.

 

Experimental or Investigational Use

 

  • If Prolia is used for conditions that are deemed experimental or investigational, EmblemHealth may not provide coverage. This typically applies to off-label uses that lack sufficient evidence of efficacy.

 

Lack of Documentation

 

  • Claims may be denied if there is insufficient documentation to justify the medical necessity of Prolia. Detailed medical records and history of osteoporosis or related conditions are required for approval.

 

Not Meeting Clinical Criteria

 

  • EmblemHealth requires that certain clinical criteria be met for Prolia coverage. Denial may occur if these specific criteria are not sufficiently met according to their policy guidelines.

 

Plan Exclusions and Limitations

 

  • Certain health plans may have specific exclusions regarding the coverage of Prolia. Review of the individual's benefit plan is necessary to determine specific exclusions or limitations.

 

Duplicate Therapy

 

  • If Prolia is prescribed in conjunction with other osteoporosis treatments without a clear clinical indication, it may be considered duplicate therapy and not eligible for coverage.

 

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

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.

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

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 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.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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.