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Does Humana Cover Prolia

Explore Humana's coverage of Prolia, reasons for denial, steps to secure coverage, costs without insurance, and frequently asked questions.

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Does Humana Cover Prolia?

Humana insurance may cover Prolia, but coverage varies depending on the specific plan you have. It's essential to verify your benefits by contacting Humana directly or checking your plan details.

Prolia is typically covered for individuals with specific conditions such as osteoporosis in postmenopausal women or men at high risk of fractures, as well as for patients who cannot use other treatment options.

Certain prerequisites may be required for coverage, such as a prior authorization or a demonstration of medical necessity from your healthcare provider.

Eligibility often depends on whether conservative treatments have failed, and your healthcare provider may need to submit documentation or evidence supporting the need for Prolia.

Copayments or coinsurance fees may apply, and understanding your out-of-pocket costs requires reviewing your specific plan’s coverage information.

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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 Humana

Verify Your Plan Details

Access your Humana member account online to review your current health insurance plan. Confirm that your plan includes prescription drug coverage, as Prolia falls under this category.

Check your plan's formulary, which is a list of covered medications. Look for Prolia to see if it is already included under your plan.

Consult Your Healthcare Provider

Ensure that a healthcare provider prescribes Prolia. Having a prescription from an approved healthcare provider is usually necessary for insurance coverage.

Discuss with your provider the medical necessity for Prolia. Documentation of medical necessity might be required by Humana for coverage approval.

Contact Humana's Customer Service

Reach out to Humana's customer service or member services through the phone number provided on your insurance card.

Inquire about the specific requirements and documentation needed for Prolia to be covered under your plan. Discuss your current prescription coverage specifics.

Complete Necessary Paperwork

Obtain any required pre-authorization forms from your healthcare provider or directly from Humana, if necessary. These forms are typically required for coverage of specialty medications like Prolia.

Work with your provider to fill out and submit these forms accurately, including providing any necessary documentation of medical necessity.

Submit a Prior Authorization Request

If required, make sure a prior authorization request is submitted to Humana for Prolia coverage. This process involves Humana evaluating the medical necessity and the appropriateness of the drug for your condition.

Ensure that your healthcare provider submits any supporting documentation as part of the prior authorization process. This might include medical records, history of treatment, and rationale for prescribing Prolia.

Check the Status of Your Request

Regularly check the status of your prior authorization request with Humana, either by calling customer service or through your online member portal.

Keep records of all correspondence and documentation submitted during the process, in case any issues arise or further information is needed.

Wait for Approval and Confirm Coverage

Once you receive approval, confirm the details of your Prolia coverage with Humana, including co-pay amounts, coverage limits, and any other pertinent information.

If there are any issues or if coverage is denied, ask for an explanation and explore the option to appeal the decision or provide additional documentation if required.

Fill Your Prescription

Take your approved prescription to a pharmacy that works with Humana to fill Prolia. You may also be required to use a specialty pharmacy as dictated by Humana.

Ensure you understand the co-payment process and have adequate information about any out-of-pocket costs you might incur for Prolia.

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FAQs

Does Humana Cover Prolia

Explore Humana's coverage of Prolia, reasons for denial, steps to secure coverage, costs without insurance, and frequently asked questions.

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Is Prolia Covered by Humana

Does Humana Cover Prolia?

Humana insurance may cover Prolia, but coverage varies depending on the specific plan you have. It's essential to verify your benefits by contacting Humana directly or checking your plan details.

Prolia is typically covered for individuals with specific conditions such as osteoporosis in postmenopausal women or men at high risk of fractures, as well as for patients who cannot use other treatment options.

Certain prerequisites may be required for coverage, such as a prior authorization or a demonstration of medical necessity from your healthcare provider.

Eligibility often depends on whether conservative treatments have failed, and your healthcare provider may need to submit documentation or evidence supporting the need for Prolia.

Copayments or coinsurance fees may apply, and understanding your out-of-pocket costs requires reviewing your specific plan’s coverage information.

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Humana's Approved Criteria for Prolia Coverage

Coverage Criteria for Prolia Under Humana

Patients diagnosed with postmenopausal osteoporosis who are at a high risk of fracture.

Individuals with a history of osteoporotic fracture, multiple risk factors for fracture, or those who have failed or are intolerant to other osteoporosis therapy options.

Patients with osteoporosis who are on chronic glucocorticoid therapy and have an elevated risk of fracture.

Men with osteoporosis who are at a high risk of fracture and have not responded adequately to other available osteoporosis therapies.

Individuals with specific medical indications that justify the use of Prolia as outlined by the treating physician and aligned with Humana's medical policy guidelines.

Why Humana Might Deny Prolia Coverage

Situations When Humana Does Not Cover Prolia

Prolia is prescribed for conditions or diagnoses not recognized as medically necessary under Humana's policy guidelines.

The prescription is for off-label use that has not been pre-approved by Humana.

The patient's medical records do not demonstrate a prior failure or contraindication to other osteoporosis treatments as required by policy.

Coverage requests are submitted without complete or adequate documentation supporting the medical necessity of Prolia.

The individual does not meet the age or specific demographic criteria set forth by Humana's clinical coverage policy.

The prescribed dosage or frequency exceeds the standard recommended limits without valid medical justification to support an exception.

Prolia is being requested as a preventive treatment in the absence of diagnosed osteoporosis or documented high fracture risk.

The patient has not undergone a recent bone density test to confirm the necessity of treatment with Prolia, where Humana policy mandates such testing.

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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 Humana

Verify Your Plan Details

Access your Humana member account online to review your current health insurance plan. Confirm that your plan includes prescription drug coverage, as Prolia falls under this category.

Check your plan's formulary, which is a list of covered medications. Look for Prolia to see if it is already included under your plan.

Consult Your Healthcare Provider

Ensure that a healthcare provider prescribes Prolia. Having a prescription from an approved healthcare provider is usually necessary for insurance coverage.

Discuss with your provider the medical necessity for Prolia. Documentation of medical necessity might be required by Humana for coverage approval.

Contact Humana's Customer Service

Reach out to Humana's customer service or member services through the phone number provided on your insurance card.

Inquire about the specific requirements and documentation needed for Prolia to be covered under your plan. Discuss your current prescription coverage specifics.

Complete Necessary Paperwork

Obtain any required pre-authorization forms from your healthcare provider or directly from Humana, if necessary. These forms are typically required for coverage of specialty medications like Prolia.

Work with your provider to fill out and submit these forms accurately, including providing any necessary documentation of medical necessity.

Submit a Prior Authorization Request

If required, make sure a prior authorization request is submitted to Humana for Prolia coverage. This process involves Humana evaluating the medical necessity and the appropriateness of the drug for your condition.

Ensure that your healthcare provider submits any supporting documentation as part of the prior authorization process. This might include medical records, history of treatment, and rationale for prescribing Prolia.

Check the Status of Your Request

Regularly check the status of your prior authorization request with Humana, either by calling customer service or through your online member portal.

Keep records of all correspondence and documentation submitted during the process, in case any issues arise or further information is needed.

Wait for Approval and Confirm Coverage

Once you receive approval, confirm the details of your Prolia coverage with Humana, including co-pay amounts, coverage limits, and any other pertinent information.

If there are any issues or if coverage is denied, ask for an explanation and explore the option to appeal the decision or provide additional documentation if required.

Fill Your Prescription

Take your approved prescription to a pharmacy that works with Humana to fill Prolia. You may also be required to use a specialty pharmacy as dictated by Humana.

Ensure you understand the co-payment process and have adequate information about any out-of-pocket costs you might incur for Prolia.

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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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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.

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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 Humana Cover Prolia

Explore Humana's coverage of Prolia, reasons for denial, steps to secure coverage, costs without insurance, and frequently asked questions.

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