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Does MDwise Cover Prolia

Explore MDwise's Prolia coverage details, reasons for denial, ways to secure coverage, Prolia costs without insurance, and common FAQs.

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Does MDwise Cover Prolia?

MDwise may cover Prolia (denosumab) under certain circumstances, primarily when it is deemed medically necessary and the patient meets specific criteria.

Coverage typically applies to patients with osteoporosis at high risk of fractures or those who have failed or are intolerant to other osteoporosis therapies.

Basic Rules and Criteria

A prior authorization may be required, involving a healthcare provider submitting documentation to demonstrate the medical necessity of Prolia.

Patients usually need to meet criteria such as a history of fractures, low bone density, or other risk factors for fracture.

Insurance plans may have specific guidelines or formularies, so it's advisable to check the latest policy details directly with MDwise or consult with a healthcare provider.

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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 MDwise

Understanding MDwise and Prolia Coverage

Reach out to MDwise customer service for specific guidance regarding Prolia coverage and to gather essential documentation and forms you might need.

Visit the MDwise website or member portal to explore the detailed benefits available under your specific plan and check if Prolia is mentioned in the formulary.

Consulting Your Healthcare Provider

Discuss with your doctor or healthcare provider the medical necessity of Prolia for your condition to ensure the proper documentation is available.

Request that your healthcare provider writes a detailed justification or prior authorization request to MDwise, explaining why Prolia is necessary for your treatment.

Submitting a Prior Authorization

Gather all relevant documents including your healthcare provider’s notes, lab results, and any previous medication history to support your case.

Log into the MDwise member portal or contact their support team to initiate the prior authorization process for Prolia. Ensure you upload or send all necessary documentation.

Follow-Up and Monitoring

Regularly check the status of your prior authorization request through the member portal or by calling MDwise customer service.

If your request is denied, inquire about the appeals process. Gather further supporting documentation and work with your healthcare provider to submit an appeal.

Understanding Costs and Copayments

Upon approval, review any out-of-pocket costs or copayments associated with accessing Prolia under your MDwise plan by checking with their customer service or online account.

Consider enrolling in any available MDwise savings program or assistance program if costs are a concern.

Stay Updated and Informed

Keep abreast of any policy changes by MDwise regarding coverage so you can maintain access to your treatment without interruptions.

Regularly update your healthcare provider on any changes to your insurance coverage or health status that might impact your treatment plan.

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FAQs

Does MDwise Cover Prolia

Explore MDwise's Prolia coverage details, reasons for denial, ways to secure coverage, Prolia costs without insurance, and common FAQs.

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Is Prolia Covered by MDwise

Does MDwise Cover Prolia?

MDwise may cover Prolia (denosumab) under certain circumstances, primarily when it is deemed medically necessary and the patient meets specific criteria.

Coverage typically applies to patients with osteoporosis at high risk of fractures or those who have failed or are intolerant to other osteoporosis therapies.

Basic Rules and Criteria

A prior authorization may be required, involving a healthcare provider submitting documentation to demonstrate the medical necessity of Prolia.

Patients usually need to meet criteria such as a history of fractures, low bone density, or other risk factors for fracture.

Insurance plans may have specific guidelines or formularies, so it's advisable to check the latest policy details directly with MDwise or consult with a healthcare provider.

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MDwise's Approved Criteria for Prolia Coverage

Eligibility Criteria for Prolia Coverage

Coverage is available for individuals diagnosed with osteoporosis who are at high risk for fracture, as determined by their healthcare provider.

Postmenopausal women with osteoporosis who have experienced a fracture or multiple risk factors for fractures may be eligible for Prolia coverage.

Men with osteoporosis who have a history of fractures or multiple risk factors for fractures and are at high risk for future fractures are also covered.

Candidates for Prolia must have a documented history of inadequate response to, or intolerance of, other osteoporosis therapies, such as bisphosphonates.

Documentation and Verification

Providers must submit a detailed medical history documenting the patient's condition and previous treatments for osteoporosis.

Verification of the patient's risk factors and history of fractures must be included in the supporting documents.

The physician must provide evidence of the patient's previous inadequate response to or intolerance of bisphosphonates, or other osteoporosis treatments.

Prescribing Requirements

Prolia must be prescribed by a licensed healthcare professional with experience in managing osteoporosis in high-risk individuals.

A comprehensive treatment plan, including Prolia administration schedule and additional support measures, must be defined and submitted with the coverage request.

A follow-up assessment plan to monitor the patient's response to treatment and any adverse effects must be included as part of the initial request.

Renewal Criteria

Continued coverage for Prolia is contingent upon demonstrated improvement or maintenance of bone density, as evidenced by follow-up assessments.

Documentation for renewal must include a report on fracture incidence and any side effects experienced during the treatment period.

Physician's documentation should confirm the need to continue Prolia based on the patient's ongoing risk factors and response to the treatment.

Why MDwise Might Deny Prolia Coverage

Situations Where MDwise Might Deny Prolia Coverage

The patient does not meet the specific medical criteria required for Prolia. This could include not having a proper diagnosis of osteoporosis or a related condition that Prolia is approved to treat.

Prolia is being prescribed for a condition not approved by the FDA. Off-label use of the medication might not be covered, leading to denial in such cases.

Lack of documented failure with other first-line osteoporosis treatments. MDwise may require evidence that other, less costly treatments have been tried and failed before approving Prolia.

The patient is not within the age range or demographic that the policy covers for the medication's use. Age-related criteria could impact coverage when prescribing Prolia.

The healthcare provider prescribing Prolia is not within the MDwise network, or there is outdated or incomplete information on the prescribing doctor or clinic.

Prolia is prescribed in a manner not consistent with MDwise's established treatment protocol or dosing guidelines. Deviations from these might lead to coverage denial.

The patient’s policy may not include comprehensive drug coverage, or there exists a specific exclusion for Prolia under their current policy terms.

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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 MDwise

Understanding MDwise and Prolia Coverage

Reach out to MDwise customer service for specific guidance regarding Prolia coverage and to gather essential documentation and forms you might need.

Visit the MDwise website or member portal to explore the detailed benefits available under your specific plan and check if Prolia is mentioned in the formulary.

Consulting Your Healthcare Provider

Discuss with your doctor or healthcare provider the medical necessity of Prolia for your condition to ensure the proper documentation is available.

Request that your healthcare provider writes a detailed justification or prior authorization request to MDwise, explaining why Prolia is necessary for your treatment.

Submitting a Prior Authorization

Gather all relevant documents including your healthcare provider’s notes, lab results, and any previous medication history to support your case.

Log into the MDwise member portal or contact their support team to initiate the prior authorization process for Prolia. Ensure you upload or send all necessary documentation.

Follow-Up and Monitoring

Regularly check the status of your prior authorization request through the member portal or by calling MDwise customer service.

If your request is denied, inquire about the appeals process. Gather further supporting documentation and work with your healthcare provider to submit an appeal.

Understanding Costs and Copayments

Upon approval, review any out-of-pocket costs or copayments associated with accessing Prolia under your MDwise plan by checking with their customer service or online account.

Consider enrolling in any available MDwise savings program or assistance program if costs are a concern.

Stay Updated and Informed

Keep abreast of any policy changes by MDwise regarding coverage so you can maintain access to your treatment without interruptions.

Regularly update your healthcare provider on any changes to your insurance coverage or health status that might impact your treatment plan.

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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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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.

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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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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 MDwise Cover Prolia

Explore MDwise's Prolia coverage details, reasons for denial, ways to secure coverage, Prolia costs without insurance, and common FAQs.

Achieve Your Goals Faster with Curex