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Does Fallon Community Health Plan (FCHP) Cover Prolia

Explore Prolia coverage under FCHP, reasons for denial, steps to obtain coverage, cost without insurance, and FAQs in this comprehensive guide.

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FCHP Coverage for Prolia

Prolia is covered by Fallon Community Health Plan, primarily under the prescription drug benefits.

Coverage typically applies to patients diagnosed with osteoporosis, especially postmenopausal women at high risk for fractures.

For men, Prolia may be covered if there's a high risk for fracture due to hypogonadism or other conditions.

Pre-authorization is often required, and a healthcare provider must verify the medical necessity based on bone density scores or fracture history.

Criteria for Approval

Patients must generally attempt treatment with other osteoporosis medications unless contraindicated or ineffective.

Documentation supporting the necessity for Prolia is essential, such as DEXA scan results and medical history.

Approval usually involves a collaborative assessment including input from the patient's healthcare provider and the FCHP clinical team.

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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 Fallon Community Health Plan (FCHP)

Initial Contact with Fallon Community Health Plan (FCHP)

Contact Fallon Community Health Plan's customer service to inquire about their pharmacy benefits and specifically ask about Prolia coverage. This can often be done through the phone number on the back of your insurance card or through the member portal on their website.

Request detailed information on the plan’s policy regarding coverage for Prolia, including any requirements or restrictions that might apply.

Check Coverage Guidelines and Requirements

Review the documentation provided by FCHP or available on their website. Look for clinical guidelines or conditions under which Prolia is covered, such as prior authorizations, step therapy, or specific medical conditions.

Verify if there's a formulary drug list provided by Fallon Community Health Plan and confirm if Prolia is listed as a covered medication.

Consult with Your Healthcare Provider

Discuss with your doctor about the need for Prolia, making sure they understand your insurance requirements to help assist in obtaining necessary authorizations.

Have your doctor prepare any documentation or notes that detail the medical necessity for Prolia, which can strengthen your case for insurance approval.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a prior authorization request to Fallon Community Health Plan. This often includes submitting your doctor’s documentation that supports the need for Prolia.

Ensure that all necessary paperwork is filled out accurately and submitted through the appropriate channels specified by FCHP for authorization requests.

Follow Up on Authorization Status

After submission, regularly follow up with FCHP to check on the status of your prior authorization. This can prevent delays and ensure that your request receives prompt attention.

If any additional information is needed, promptly work with your doctor to provide further documentation or clarifications.

Understand Appeal Process if Denied

If the prior authorization request is denied, carefully review the denial letter for reasons and understand your rights to appeal the decision.

Gather additional supporting materials or evidence of medical necessity and submit an appeal by following the specific guidelines and timelines provided by FCHP.

Monitor Coverage and Benefits Updates

Regularly check for any changes in your FCHP coverage policies, especially during open enrollment or policy renewal times.

Stay informed about new updates or modifications to Fallon’s drug formulary that might impact Prolia’s coverage.

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Does Fallon Community Health Plan (FCHP) Cover Prolia

Explore Prolia coverage under FCHP, reasons for denial, steps to obtain coverage, cost without insurance, and FAQs in this comprehensive guide.

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Is Prolia Covered by Fallon Community Health Plan (FCHP)

FCHP Coverage for Prolia

Prolia is covered by Fallon Community Health Plan, primarily under the prescription drug benefits.

Coverage typically applies to patients diagnosed with osteoporosis, especially postmenopausal women at high risk for fractures.

For men, Prolia may be covered if there's a high risk for fracture due to hypogonadism or other conditions.

Pre-authorization is often required, and a healthcare provider must verify the medical necessity based on bone density scores or fracture history.

Criteria for Approval

Patients must generally attempt treatment with other osteoporosis medications unless contraindicated or ineffective.

Documentation supporting the necessity for Prolia is essential, such as DEXA scan results and medical history.

Approval usually involves a collaborative assessment including input from the patient's healthcare provider and the FCHP clinical team.

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Fallon Community Health Plan (FCHP)'s Approved Criteria for Prolia Coverage

Fallon Community Health Plan (FCHP) Criteria for Prolia Coverage

**Postmenopausal Women with Osteoporosis**
- Prolia may be covered for postmenopausal women diagnosed with osteoporosis who are at high risk for fracture.
- Documentation of a bone mineral density (BMD) T-score of -2.5 or lower is required.
- History of an osteoporotic fracture or presence of other clinical risk factors for fracture.
- Failure or intolerance to other osteoporosis therapies such as bisphosphonates.

**Men with Osteoporosis**
- Prolia may be covered for men with high risk of fracture due to primary or hypogonadal osteoporosis.
- Documentation of a BMD T-score of -2.5 or lower is needed, or evidence of fracture risk.
- Failure, intolerance, or contraindication to other standard osteoporosis therapies is necessary.

**Glucocorticoid-Induced Osteoporosis**
- Prolia may be considered for patients continuously receiving glucocorticoids at a dose equivalent to 7.5 mg or more of prednisone daily for at least three months.
- Patient must be at high risk for fracture, defined by failure or intolerance to other preventive osteoporosis treatments.

**Treatment of Bone Loss in Patients with Prostate or Breast Cancer**
- Coverage may be available for men with non-metastatic prostate cancer or women with nonmetastatic breast cancer who are receiving adjuvant therapy that causes bone loss (such as androgen deprivation therapy for prostate cancer or aromatase inhibitor therapy for breast cancer).
- Prolia may be prescribed to increase bone mass in these patients.

Why Fallon Community Health Plan (FCHP) Might Deny Prolia Coverage

Situations Where FCHP Might Deny Prolia Coverage

Prolia is requested for conditions that are not FDA-approved or listed as experimental or investigational.

The patient does not meet the documented criteria for osteoporosis treatment as per FCHP medical policies, such as not fulfilling specific bone density parameters.

Failure to demonstrate prior unsuccessful response or intolerance to alternative osteoporosis treatments which are standard protocol before coverage for Prolia is granted.

Lack of sufficient medical documentation or failure to provide necessary lab results and medical history to support the prescription requirement.

Request for use in patients without documented high fracture risk as determined by established guidelines.

Prescriptions initiated by non-authorized prescribers or those outside of network agreements as stipulated by the plan's policy.

Prolia is being considered for a patient whose records indicate unresolved issues or non-compliance with previous osteoporosis 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 Fallon Community Health Plan (FCHP)

Initial Contact with Fallon Community Health Plan (FCHP)

Contact Fallon Community Health Plan's customer service to inquire about their pharmacy benefits and specifically ask about Prolia coverage. This can often be done through the phone number on the back of your insurance card or through the member portal on their website.

Request detailed information on the plan’s policy regarding coverage for Prolia, including any requirements or restrictions that might apply.

Check Coverage Guidelines and Requirements

Review the documentation provided by FCHP or available on their website. Look for clinical guidelines or conditions under which Prolia is covered, such as prior authorizations, step therapy, or specific medical conditions.

Verify if there's a formulary drug list provided by Fallon Community Health Plan and confirm if Prolia is listed as a covered medication.

Consult with Your Healthcare Provider

Discuss with your doctor about the need for Prolia, making sure they understand your insurance requirements to help assist in obtaining necessary authorizations.

Have your doctor prepare any documentation or notes that detail the medical necessity for Prolia, which can strengthen your case for insurance approval.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a prior authorization request to Fallon Community Health Plan. This often includes submitting your doctor’s documentation that supports the need for Prolia.

Ensure that all necessary paperwork is filled out accurately and submitted through the appropriate channels specified by FCHP for authorization requests.

Follow Up on Authorization Status

After submission, regularly follow up with FCHP to check on the status of your prior authorization. This can prevent delays and ensure that your request receives prompt attention.

If any additional information is needed, promptly work with your doctor to provide further documentation or clarifications.

Understand Appeal Process if Denied

If the prior authorization request is denied, carefully review the denial letter for reasons and understand your rights to appeal the decision.

Gather additional supporting materials or evidence of medical necessity and submit an appeal by following the specific guidelines and timelines provided by FCHP.

Monitor Coverage and Benefits Updates

Regularly check for any changes in your FCHP coverage policies, especially during open enrollment or policy renewal times.

Stay informed about new updates or modifications to Fallon’s drug formulary that might impact Prolia’s coverage.

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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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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 Fallon Community Health Plan (FCHP) Cover Prolia

Explore Prolia coverage under FCHP, reasons for denial, steps to obtain coverage, cost without insurance, and FAQs in this comprehensive guide.

Achieve Your Goals Faster with Curex