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Does Geisinger Health Plan Cover Prolia

Find out if Geisinger Health Plan covers Prolia, explore denial reasons, learn how to secure coverage, uncover costs, and get answers to FAQs.

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Overview of Prolia Coverage

Geisinger Health Plan often covers Prolia for patients meeting specific medical criteria because Prolia is a prescribed medication used to treat osteoporosis.

Eligibility Criteria

Typically requires a diagnosis of osteoporosis with high risk of fracture.
Patient must have inadequate response or intolerance to other osteoporosis treatments.
Doctor's prescription and prior authorization are usually necessary.

Coverage Conditions

Coverage details may depend on the specific Geisinger plan.
Patients may need to meet age and health condition requirements.
Certain plan benefits and limitations apply, check specific policy.

Steps to Secure Coverage

Consult with your healthcare provider to ensure Prolia is appropriate.
Work with your provider to submit any necessary documentation for prior authorization.
Verify coverage with Geisinger Health Plan customer service to understand out-of-pocket costs if applicable.

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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 Geisinger Health Plan

Understand the Insurance and Drug Coverage

Start by reviewing your Geisinger Health Plan documentation or member handbook for information on prescription drug coverage.
Contact Geisinger Customer Service to inquire specifically about coverage for Prolia, a medication typically used for osteoporosis treatment.
Make sure to ask about any specific criteria or pre-approval required for Prolia to be covered under your plan.

Consult Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Prolia.
Ensure your healthcare provider is aware that you are seeking coverage for Prolia through Geisinger Health Plan.
Request that your healthcare provider gathers necessary documentation, such as your diagnosis and medical history, which may be needed for insurance purposes.

Prior Authorization Process

Some insurance plans, including those under Geisinger, might require prior authorization for coverage of certain medications like Prolia.
Work with your healthcare provider to submit a prior authorization request to Geisinger Health Plan.
Include all required documentation, such as medical necessity, mentioned by Geisinger in your plan details.

Check for Preferred Pharmacies

Verify if Geisinger Health Plan has a list of preferred pharmacies for filling your Prolia prescription.
Use a pharmacy that participates in your plan's network to possibly reduce out-of-pocket costs.

Appeal if Necessary

If your request for Prolia coverage is denied, carefully review the reason for denial provided by Geisinger Health Plan.
Consult with your healthcare provider to address any issues and gather additional supporting documents if necessary.
Follow Geisinger's appeal process outlined in your plan documentation to contest the denial.

Ongoing Communication

Regularly communicate with Geisinger Health Plan and your healthcare provider to ensure continuous coverage for Prolia.
Stay informed about any policy changes that might affect your prescription drug coverage.

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FAQs

Does Geisinger Health Plan Cover Prolia

Find out if Geisinger Health Plan covers Prolia, explore denial reasons, learn how to secure coverage, uncover costs, and get answers to FAQs.

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Is Prolia Covered by Geisinger Health Plan

Overview of Prolia Coverage

Geisinger Health Plan often covers Prolia for patients meeting specific medical criteria because Prolia is a prescribed medication used to treat osteoporosis.

Eligibility Criteria

Typically requires a diagnosis of osteoporosis with high risk of fracture.
Patient must have inadequate response or intolerance to other osteoporosis treatments.
Doctor's prescription and prior authorization are usually necessary.

Coverage Conditions

Coverage details may depend on the specific Geisinger plan.
Patients may need to meet age and health condition requirements.
Certain plan benefits and limitations apply, check specific policy.

Steps to Secure Coverage

Consult with your healthcare provider to ensure Prolia is appropriate.
Work with your provider to submit any necessary documentation for prior authorization.
Verify coverage with Geisinger Health Plan customer service to understand out-of-pocket costs if applicable.

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Geisinger Health Plan's Approved Criteria for Prolia Coverage

Criteria for Prolia Coverage

**Postmenopausal Women**: The plan covers Prolia for postmenopausal women with osteoporosis who are at high risk for fracture.

**Men with Osteoporosis**: Prolia is approved for men with osteoporosis who are at an increased risk for fracture.

**Glucocorticoid-Induced Osteoporosis**: Coverage is provided for individuals (men or women) undergoing systemic glucocorticoid therapy associated with an increased risk of fractures.

**Initial Therapy**: Patients who have not responded to or are intolerant of other osteoporosis therapies may qualify.

**Bone Density Tests**: A requirement for coverage includes evidence from bone density tests indicating necessity for treatment.

**History of Fractures**: Patients with a documented history of osteoporotic fracture may meet the requirements for coverage.

**Endocrinologist or Specialist Recommendation**: Coverage is more likely approved if the prescription comes from an endocrinologist or specialist with expertise in osteoporosis management.

Why Geisinger Health Plan Might Deny Prolia Coverage

Situations When Geisinger Health Plan Does Not Cover Prolia

The patient does not meet the medical necessity criteria established by Geisinger Health Plan for Prolia treatment, which typically includes specific diagnostic criteria or severity of osteoporosis.

The patient has not tried or failed alternative osteoporosis treatments if those are considered appropriate before advancing to Prolia.

Prolia is sought for indications outside of its FDA-approved uses or for experimental/investigational purposes not recognized by Geisinger Health Plan.

There is duplicate therapy, where the patient is already receiving another medication with similar effects or benefits.

Prescription is from a healthcare provider who is not within the Geisinger Health Plan's network, and there is no exception or prior authorization.

Coverage period requirements or step therapy protocols have not been adhered to, such as failure to demonstrate previous medication history as stipulated by the plan.

The patient does not comply with necessary documentation or prior authorization processes that Geisinger Health Plan mandates before approval.

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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 Geisinger Health Plan

Understand the Insurance and Drug Coverage

Start by reviewing your Geisinger Health Plan documentation or member handbook for information on prescription drug coverage.
Contact Geisinger Customer Service to inquire specifically about coverage for Prolia, a medication typically used for osteoporosis treatment.
Make sure to ask about any specific criteria or pre-approval required for Prolia to be covered under your plan.

Consult Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Prolia.
Ensure your healthcare provider is aware that you are seeking coverage for Prolia through Geisinger Health Plan.
Request that your healthcare provider gathers necessary documentation, such as your diagnosis and medical history, which may be needed for insurance purposes.

Prior Authorization Process

Some insurance plans, including those under Geisinger, might require prior authorization for coverage of certain medications like Prolia.
Work with your healthcare provider to submit a prior authorization request to Geisinger Health Plan.
Include all required documentation, such as medical necessity, mentioned by Geisinger in your plan details.

Check for Preferred Pharmacies

Verify if Geisinger Health Plan has a list of preferred pharmacies for filling your Prolia prescription.
Use a pharmacy that participates in your plan's network to possibly reduce out-of-pocket costs.

Appeal if Necessary

If your request for Prolia coverage is denied, carefully review the reason for denial provided by Geisinger Health Plan.
Consult with your healthcare provider to address any issues and gather additional supporting documents if necessary.
Follow Geisinger's appeal process outlined in your plan documentation to contest the denial.

Ongoing Communication

Regularly communicate with Geisinger Health Plan and your healthcare provider to ensure continuous coverage for Prolia.
Stay informed about any policy changes that might affect your prescription drug 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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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 Geisinger Health Plan Cover Prolia

Find out if Geisinger Health Plan covers Prolia, explore denial reasons, learn how to secure coverage, uncover costs, and get answers to FAQs.

Achieve Your Goals Faster with Curex