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Does Florida Blue (Blue Cross Blue Shield of Florida) Cover Prolia

Learn about Florida Blue's Prolia coverage, reasons for denial, costs without insurance, and find answers to frequent questions in this concise guide.

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Florida Blue Coverage for Prolia

Florida Blue may cover Prolia for osteoporosis in postmenopausal women with a high fracture risk.

It can be covered for men with osteoporosis at high risk for fracture or if other treatments have failed.

Patients with glucocorticoid-induced osteoporosis might also qualify for coverage under specific conditions.

Criteria for Coverage

Patients often need pre-authorization, verifying they meet medical criteria and that other treatments have been ineffective.

Doctors typically must justify the need through medical records and demonstrate a high risk of fractures.

Certain plans may require the patient to try and fail on other osteoporosis treatments before approving Prolia.

General Rules

Coverage specifics can vary by plan; patients should consult their specific policy details or contact Florida Blue directly.

Patients might need to use in-network providers and pharmacies to ensure coverage.

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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 Florida Blue (Blue Cross Blue Shield of Florida)

Verify Your Plan Details

Review your Florida Blue insurance plan to see if it includes prescription drug coverage. Prolia is usually covered under such plans, but specific details can vary.

Log into your Florida Blue account online or refer to your policy documentation to confirm coverage for specialty medications like Prolia.

Consult Your Healthcare Provider

Discuss with your doctor the medical necessity of Prolia for your condition. They may need to provide documentation to support the need for this specific treatment.

Ask your healthcare provider to write a prescription for Prolia, ensuring they include all necessary medical information that may be required by Florida Blue.

Contact Florida Blue

Call the customer service number on the back of your Florida Blue insurance card to speak with a representative about Prolia coverage.

Inquire about any prior authorization or documentation needed before Prolia can be covered under your plan. Take notes on any specific steps or forms you need to complete.

Obtain Prior Authorization

Work with your healthcare provider to submit any necessary prior authorization forms to Florida Blue. This step is crucial for obtaining coverage for specialty medications.

Ensure that all forms are filled out completely and accurately, including relevant medical history and reason for prescribing Prolia.

Follow Up with Insurance

After submitting prior authorization, follow up with Florida Blue to confirm receipt and find out the status of your request.

Be proactive in checking for approval and inquire about the expected timeline for decision-making.

Explore Financial Assistance

If coverage is denied, ask Florida Blue about appealing the decision, or investigate financial assistance programs that can help with Prolia costs.

Contact the manufacturer of Prolia, as they may offer patient assistance programs or rebates to help offset costs.

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FAQs

Does Florida Blue (Blue Cross Blue Shield of Florida) Cover Prolia

Learn about Florida Blue's Prolia coverage, reasons for denial, costs without insurance, and find answers to frequent questions in this concise guide.

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Is Prolia Covered by Florida Blue (Blue Cross Blue Shield of Florida)

Florida Blue Coverage for Prolia

Florida Blue may cover Prolia for osteoporosis in postmenopausal women with a high fracture risk.

It can be covered for men with osteoporosis at high risk for fracture or if other treatments have failed.

Patients with glucocorticoid-induced osteoporosis might also qualify for coverage under specific conditions.

Criteria for Coverage

Patients often need pre-authorization, verifying they meet medical criteria and that other treatments have been ineffective.

Doctors typically must justify the need through medical records and demonstrate a high risk of fractures.

Certain plans may require the patient to try and fail on other osteoporosis treatments before approving Prolia.

General Rules

Coverage specifics can vary by plan; patients should consult their specific policy details or contact Florida Blue directly.

Patients might need to use in-network providers and pharmacies to ensure coverage.

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Florida Blue (Blue Cross Blue Shield of Florida)'s Approved Criteria for Prolia Coverage

Prolia Coverage Criteria

**Diagnosis of Osteoporosis**: Prolia is covered for patients with a documented diagnosis of osteoporosis, confirmed by a bone mineral density (BMD) test with a T-score of -2.5 or lower.

**Postmenopausal Women**: Prolia is covered for postmenopausal women who are at high risk for fracture, especially those with a history of osteoporotic fracture.

**Men at High Risk for Fracture**: Coverage is available for men who have been diagnosed with osteoporosis and are at an increased risk of fracture.

**Concurrent Glucocorticoid Therapy**: Patients undergoing long-term glucocorticoid therapy (equivalent to 5mg or more of prednisone daily) who are at a high risk of fracture may qualify for Prolia coverage.

**Failure or Intolerance to Other Therapies**: Prolia is covered for patients who have shown failure or intolerance to oral bisphosphonates or other osteoporosis treatments.

**Bone Loss Due to Hormone Ablation**: Prolia is covered for patients receiving androgen deprivation therapy for nonmetastatic prostate cancer or adjuvant aromatase inhibitor therapy for breast cancer, experiencing bone loss as a result of these treatments.

Why Florida Blue (Blue Cross Blue Shield of Florida) Might Deny Prolia Coverage

Prolia Coverage Exclusions

Prolia is not covered if prescribed outside of FDA-approved indications or uses not supported by current medical guidelines.

The medication is excluded from coverage if an individual's medical history does not demonstrate a failure of, or contraindication to, first-line osteoporosis treatments.

Florida Blue may deny coverage if proper documentation is not provided, illustrating the medical necessity and prior history of inadequate response to other therapies.

Prolia will not be covered for off-label uses that lack sufficient clinical evidence or acceptance in standard medical practice.

Coverage might be denied if there’s no verification of osteoporosis-related fracture risk or a significant reduction in bone mineral density in patients who do not have a qualifying diagnosis.

Cases where Prolia is requested for conditions not primarily related to bone density conservation (e.g., routine arthritis treatment) may also be denied coverage.

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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 Florida Blue (Blue Cross Blue Shield of Florida)

Verify Your Plan Details

Review your Florida Blue insurance plan to see if it includes prescription drug coverage. Prolia is usually covered under such plans, but specific details can vary.

Log into your Florida Blue account online or refer to your policy documentation to confirm coverage for specialty medications like Prolia.

Consult Your Healthcare Provider

Discuss with your doctor the medical necessity of Prolia for your condition. They may need to provide documentation to support the need for this specific treatment.

Ask your healthcare provider to write a prescription for Prolia, ensuring they include all necessary medical information that may be required by Florida Blue.

Contact Florida Blue

Call the customer service number on the back of your Florida Blue insurance card to speak with a representative about Prolia coverage.

Inquire about any prior authorization or documentation needed before Prolia can be covered under your plan. Take notes on any specific steps or forms you need to complete.

Obtain Prior Authorization

Work with your healthcare provider to submit any necessary prior authorization forms to Florida Blue. This step is crucial for obtaining coverage for specialty medications.

Ensure that all forms are filled out completely and accurately, including relevant medical history and reason for prescribing Prolia.

Follow Up with Insurance

After submitting prior authorization, follow up with Florida Blue to confirm receipt and find out the status of your request.

Be proactive in checking for approval and inquire about the expected timeline for decision-making.

Explore Financial Assistance

If coverage is denied, ask Florida Blue about appealing the decision, or investigate financial assistance programs that can help with Prolia costs.

Contact the manufacturer of Prolia, as they may offer patient assistance programs or rebates to help offset costs.

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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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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 Florida Blue (Blue Cross Blue Shield of Florida) Cover Prolia

Learn about Florida Blue's Prolia coverage, reasons for denial, costs without insurance, and find answers to frequent questions in this concise guide.

Achieve Your Goals Faster with Curex