$49$0.99

Does Highmark Cover Prolia

Explore why Highmark might deny Prolia, how to secure coverage, costs without insurance, and more in our comprehensive FAQ guide.

Treat your allergies with Curex

as seen on

“Curex is changing the landscape of allergies in 2024”

Does Highmark Cover Prolia?

Highmark covers Prolia, a medication for osteoporosis, primarily for patients who meet specific medical criteria.

Coverage is generally provided for postmenopausal women at high risk of fractures, or individuals intolerant to other osteoporosis treatments.

Patients must have a documented history of fractures related to osteoporosis or demonstrate a pattern of failing other treatments.

A prior authorization may be required, involving evidence of medical necessity and meeting established criteria, which often includes a bone mineral density test.

It's essential for providers to submit detailed patient histories and treatment records to ensure compliance with Highmark's guidelines.

Patients should consult with their healthcare provider or directly with Highmark to confirm personalized coverage specifics and any potential out-of-pocket costs.

Want to try immunotherapy?

Start with Curex

Covered

Uncovered

Treat your allergies with Curex - $49 $9.99

Review your allergy test results with a Curex allergist.

Start Now

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

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 Highmark

Gather Necessary Documentation

Ensure you have a prescription from your healthcare provider for Prolia.

Collect any medical documentation that supports the necessity for Prolia, such as bone density scan results or a history of fractures.

Verify your Highmark insurance policy documents to understand your prescription drug coverage.

Contact Highmark Customer Service

Call the customer service number on the back of your insurance card to confirm if Prolia is covered under your current plan.

Ask about the specific criteria for Prolia coverage, such as pre-authorization requirements or preferred pharmacy networks.

Write down any important details or instructions provided by the customer service representative.

Visit Your Healthcare Provider

Discuss with your healthcare provider the need for Prolia and ensure they are aware of any insurance pre-authorization requirements.

Your healthcare provider may need to submit certain documentation or fill out forms to obtain approval from Highmark.

Ensure your provider includes all necessary supporting documents, such as your medical history and reason for prescribing Prolia.

Submit Pre-Authorization Request

Work with your healthcare provider to complete and submit a pre-authorization request to Highmark.

Ensure the request includes all required information and documentation to increase the likelihood of approval.

Follow up with Highmark or your healthcare provider to confirm receipt and processing of the request.

Review Approval or Appeal Denial

If approved, review the terms of Prolia coverage, including any copayments, deductibles, or limits.

If denied, request an explanation of the decision from Highmark and discuss with your healthcare provider the possibility of appealing the decision.

Gather additional documentation or clarification for your appeal if required and resubmit to Highmark.

Arrange for Prescription Fulfillment

Once Prolia coverage is confirmed, work with your healthcare provider and a participating pharmacy to fill the prescription.

Ensure that the pharmacy is within Highmark’s network to minimize out-of-pocket costs.

Maintain copies of all correspondence and receipts for future reference or billing inquiries.

Happy Customers

We love helping people!

Allie, Nevada

"I have two cats I can finally cuddle!"
‍

Cat and dog allergies

Zachary, Texas

“I can breathe through my nose for the first time in like 20 years!"

Dust and mold allergies

Erika, New York

“I've noticed less sneezing and shortness of breath.”

Tree and grass allergies

Richard, Texas

I love the convenience!
‍

Tree and cat allergies

We Treat Allergies

Food Allergies

Weed Pollens

Cat Allergies

Dog Allergies

Dust Mites

Molds

Tree Pollens

curex user showing allergy treatment kit

a male patient showing allergy drops vial

50,000+ users have overcome their allergies

Am I eligible?

At-home Immunotherapy

Benefits of Curex

At-home treatment

Apply treatments in minutes from the comfort of your own home with under-the-tongue applications instead of shots or pills

5-30x higher cumulative dose vs allergy shots

Sublingual immunotherapy delivers a higher dose of allergens over the course of treatment.

Potential for results in as few as 6 months

Individual results vary but some users have reported a noticeable difference in as few as 6-12 months since starting treatments

Excellent safety profile

Studies that have been reviewed by certified physicians show that sublingual immunotherapy is a safe treatment option

Treatment prescribed
by clinician

Clinicaly made allergen extracts are customized for your allergies

Your immune system gets desensitized to allergens, giving you long-term relief.

FAQs

Does Highmark Cover Prolia

Explore why Highmark might deny Prolia, how to secure coverage, costs without insurance, and more in our comprehensive FAQ guide.

Achieve Your Goals Faster with Curex

Is Prolia Covered by Highmark

Does Highmark Cover Prolia?

Highmark covers Prolia, a medication for osteoporosis, primarily for patients who meet specific medical criteria.

Coverage is generally provided for postmenopausal women at high risk of fractures, or individuals intolerant to other osteoporosis treatments.

Patients must have a documented history of fractures related to osteoporosis or demonstrate a pattern of failing other treatments.

A prior authorization may be required, involving evidence of medical necessity and meeting established criteria, which often includes a bone mineral density test.

It's essential for providers to submit detailed patient histories and treatment records to ensure compliance with Highmark's guidelines.

Patients should consult with their healthcare provider or directly with Highmark to confirm personalized coverage specifics and any potential out-of-pocket costs.

A weight management program tailored to you

Start with Curex

Highmark's Approved Criteria for Prolia Coverage

Coverage Criteria for Prolia

**Patient Eligibility**: Prolia is covered for postmenopausal women with osteoporosis who have a high risk for fracture. This includes individuals with a history of osteoporotic fractures, multiple risk factors for fracture, or those who have failed or are intolerant to other available osteoporosis therapies.

**Osteoporosis Diagnosis**: An objective measure such as a bone mineral density (BMD) test with a T-score of -2.5 or lower, or a history of a fragility fracture.

**Gender and Age Criteria**: Women must be postmenopausal and typically ages 50 and above.

**Prior Therapies**: Patients must have tried and not benefited from or been intolerant to other osteoporosis treatments, such as bisphosphonates.

**Bone Density Considerations**: Patients with a BMD T-score between -1.0 and -2.5, if accompanied by high risk factors for fracture, may be considered.

**Intended Use**: Coverage applies to the prevention of fractures in high-risk patients, including vertebral and nonvertebral fractures.

**Relevant Medical History**: Coverage is approved for individuals with documented prior fragility fractures or multiple risk factors conducive to fracture.

**Administration Conditions**: Prolia is typically covered when administered in a setting capable of managing potential severe reactions, often through a healthcare provider's facility.

**Heightened Risk Conditions**: Also covers patients with conditions such as rheumatoid arthritis or other contributing factors that increase fracture risk, given documentation and recommendation by a healthcare provider.

Why Highmark Might Deny Prolia Coverage

Denial Criteria for Prolia Coverage by Highmark

Prolia is not covered for patients who do not meet the medically necessary criteria as outlined by Highmark's policy. Specific conditions or situations where the medication does not align with required medical standards will result in denial.

Coverage is denied if the patient has not tried and failed on other preferred treatment alternatives, unless contraindicated or not tolerated, according to Highmark's step therapy protocols.

Highmark denies coverage if the prescribed use of Prolia does not align with FDA-approved indications, including cases where it is prescribed for conditions not recognized as medically necessary by Highmark.

If the prescribing physician does not provide documentation of the patient's bone mineral density tests, or if such documentation does not support the diagnosis of osteoporosis or severe osteopenia according to Highmark's guidelines, coverage may be denied.

Claims are denied if the Prolia prescription is higher than the recommended dose or frequency without appropriate clinical justification.

Highmark will deny coverage if the patient is on concurrent therapy with medications considered unsafe or contraindicated when used with Prolia, unless there is adequate documentation justifying this combination.

Denials occur if claims do not comply with Highmark's prior authorization process, including failure to obtain necessary approvals before initiating treatment.

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

Join Curex

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 Highmark

Gather Necessary Documentation

Ensure you have a prescription from your healthcare provider for Prolia.

Collect any medical documentation that supports the necessity for Prolia, such as bone density scan results or a history of fractures.

Verify your Highmark insurance policy documents to understand your prescription drug coverage.

Contact Highmark Customer Service

Call the customer service number on the back of your insurance card to confirm if Prolia is covered under your current plan.

Ask about the specific criteria for Prolia coverage, such as pre-authorization requirements or preferred pharmacy networks.

Write down any important details or instructions provided by the customer service representative.

Visit Your Healthcare Provider

Discuss with your healthcare provider the need for Prolia and ensure they are aware of any insurance pre-authorization requirements.

Your healthcare provider may need to submit certain documentation or fill out forms to obtain approval from Highmark.

Ensure your provider includes all necessary supporting documents, such as your medical history and reason for prescribing Prolia.

Submit Pre-Authorization Request

Work with your healthcare provider to complete and submit a pre-authorization request to Highmark.

Ensure the request includes all required information and documentation to increase the likelihood of approval.

Follow up with Highmark or your healthcare provider to confirm receipt and processing of the request.

Review Approval or Appeal Denial

If approved, review the terms of Prolia coverage, including any copayments, deductibles, or limits.

If denied, request an explanation of the decision from Highmark and discuss with your healthcare provider the possibility of appealing the decision.

Gather additional documentation or clarification for your appeal if required and resubmit to Highmark.

Arrange for Prescription Fulfillment

Once Prolia coverage is confirmed, work with your healthcare provider and a participating pharmacy to fill the prescription.

Ensure that the pharmacy is within Highmark’s network to minimize out-of-pocket costs.

Maintain copies of all correspondence and receipts for future reference or billing inquiries.

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?

‍

Get a personalized online consultation with a doctor at Curex

Learn More

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

Button Text

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 Highmark Cover Prolia

Explore why Highmark might deny Prolia, how to secure coverage, costs without insurance, and more in our comprehensive FAQ guide.

Achieve Your Goals Faster with Curex