Does Molina Healthcare Cover Prolia

Explore Molina Healthcare's Prolia coverage, reasons for denial, how to get coverage, cost without insurance, and FAQs in this insightful article.
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Coverage of Prolia by Molina Healthcare

 

  • Molina Healthcare may cover Prolia for members who meet specific medical criteria.
  •  

  • Typically, Prolia is approved for postmenopausal women with osteoporosis at high risk of fracture, or patients who have failed other treatments.
  •  

  • A prior authorization is generally required. This means your healthcare provider must submit documentation supporting the medical necessity of Prolia.
  •  

  • Certain conditions such as glucocorticoid-induced osteoporosis or androgen deprivation therapy in men might also be covered depending on plan specifics.
  •  

  • Coverage can vary by state, so it's important to check your specific plan details and consult with your healthcare provider.

 

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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 Molina Healthcare

 

Initial Steps with Molina Healthcare

 

  • Contact Molina Healthcare’s customer service for information about their coverage policies. Look for contact information on your insurance card or the Molina website.
  •  

  • Ask specifically about Prolia coverage and any requirement steps, such as prior authorization or medical necessity documentation.

 

Verify Your Prescription Needs

 

  • Consult with your healthcare provider regarding the medical need for Prolia. Discuss your health condition to determine if Prolia is the appropriate treatment option.
  •  

  • Ensure that your provider can assist in completing any necessary forms or documentation required by Molina Healthcare for coverage approval.

 

Obtain Prior Authorization

 

  • Work with your healthcare provider to submit a prior authorization request to Molina Healthcare. This request typically involves providing medical justification for Prolia treatment.
  •  

  • Ensure that all necessary medical records and documents are included in the submission to avoid delays.

 

Check for In-Network Pharmacies

 

  • Determine if there are specific pharmacies within Molina’s network where you can fill your Prolia prescription. Using in-network pharmacies can prevent additional out-of-pocket costs.
  •  

  • Consult the Molina Healthcare website or customer service for a list of participating pharmacies.

 

Review Your Plan Benefits

 

  • Examine your specific Molina Healthcare plan’s benefits and cost-sharing obligations concerning specialty medications like Prolia.
  •  

  • Be aware of any co-pays, deductibles, or out-of-pocket maximums that might affect your medication costs.

 

Follow Up Regularly

 

  • Check regularly with Molina Healthcare and your healthcare provider about the status of your prior authorization request.
  •  

  • Be prepared to provide additional information or clarification if requested by Molina Healthcare to facilitate approval.

 

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Does Molina Healthcare Cover Prolia

Explore Molina Healthcare's Prolia coverage, reasons for denial, how to get coverage, cost without insurance, and FAQs in this insightful article.
Curex allergy drops unboxing

Is Prolia Covered by Molina Healthcare

 

Coverage of Prolia by Molina Healthcare

 

  • Molina Healthcare may cover Prolia for members who meet specific medical criteria.
  •  

  • Typically, Prolia is approved for postmenopausal women with osteoporosis at high risk of fracture, or patients who have failed other treatments.
  •  

  • A prior authorization is generally required. This means your healthcare provider must submit documentation supporting the medical necessity of Prolia.
  •  

  • Certain conditions such as glucocorticoid-induced osteoporosis or androgen deprivation therapy in men might also be covered depending on plan specifics.
  •  

  • Coverage can vary by state, so it's important to check your specific plan details and consult with your healthcare provider.

 

A weight management program tailored to you

Start with Curex

Molina Healthcare's Approved Criteria for Prolia Coverage

 

Criteria for Prolia Coverage by Molina Healthcare

 

  • Prolia is covered for the treatment of postmenopausal women with osteoporosis at high risk for fracture. This includes individuals who have a history of osteoporotic fractures or multiple risk factors for fracture.
  •  

  • Candidates for Prolia must have a documented failure or contraindication to other osteoporosis therapies, such as bisphosphonates.
  •  

  • Men with osteoporosis who are at high risk for fracture and have either sustained a fracture or are intolerant to bisphosphonates may also qualify for Prolia coverage.
  •  

  • Patients undergoing androgen deprivation therapy for nonmetastatic prostate cancer, who are at high risk for fracture, are eligible for Prolia coverage if other treatments are not suitable.
  •  

  • Women receiving adjuvant aromatase inhibitor therapy for breast cancer, who are at high risk for fracture, qualify for Prolia when alternative treatments are contraindicated or have failed.
  •  

  • All candidates must show a documented assessment of bone mineral density with established osteoporosis diagnosis to be considered eligible for Prolia under Molina Healthcare’s criteria.
  •  

  • Molina Healthcare requires prior authorization for Prolia, and the request must include clinical documentation supporting the need and specific criteria satisfied for commencement.

 

Why Molina Healthcare Might Deny Prolia Coverage

 

Situations Where Prolia Is Not Covered by Molina Healthcare

 

  • Treatment Experimental Status: Prolia may not be covered if it is deemed as experimental or investigational for certain conditions not supported by substantial clinical evidence.
  •  

  • Non-Approved Indications: If Prolia is being prescribed for conditions or diagnoses not expressly approved by the FDA, coverage might be denied.
  •  

  • Dosage and Administration: Prolia use might be excluded if the prescribed dosage or administration does not align with approved guidelines or protocols.
  •  

  • Lack of Prior Authorization: Coverage could be denied if appropriate prior authorization procedures have not been completed and approved before initiating treatment.
  •  

  • Duplicate Therapy: Prolia may not be covered if it is deemed as duplicative therapy that overlaps with other osteoporosis treatments previously covered by the plan.
  •  

  • Non-Compliance with Age Restrictions: If the patient does not meet specific age-related criteria set by Molina Healthcare for coverage of Prolia, the request may be denied.
  •  

  • Absence of Documented Medical Necessity: If there is insufficient medical documentation supporting the necessity of Prolia for the condition being treated, coverage might be denied.

 

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

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.

 

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 Molina Healthcare

 

Initial Steps with Molina Healthcare

 

  • Contact Molina Healthcare’s customer service for information about their coverage policies. Look for contact information on your insurance card or the Molina website.
  •  

  • Ask specifically about Prolia coverage and any requirement steps, such as prior authorization or medical necessity documentation.

 

Verify Your Prescription Needs

 

  • Consult with your healthcare provider regarding the medical need for Prolia. Discuss your health condition to determine if Prolia is the appropriate treatment option.
  •  

  • Ensure that your provider can assist in completing any necessary forms or documentation required by Molina Healthcare for coverage approval.

 

Obtain Prior Authorization

 

  • Work with your healthcare provider to submit a prior authorization request to Molina Healthcare. This request typically involves providing medical justification for Prolia treatment.
  •  

  • Ensure that all necessary medical records and documents are included in the submission to avoid delays.

 

Check for In-Network Pharmacies

 

  • Determine if there are specific pharmacies within Molina’s network where you can fill your Prolia prescription. Using in-network pharmacies can prevent additional out-of-pocket costs.
  •  

  • Consult the Molina Healthcare website or customer service for a list of participating pharmacies.

 

Review Your Plan Benefits

 

  • Examine your specific Molina Healthcare plan’s benefits and cost-sharing obligations concerning specialty medications like Prolia.
  •  

  • Be aware of any co-pays, deductibles, or out-of-pocket maximums that might affect your medication costs.

 

Follow Up Regularly

 

  • Check regularly with Molina Healthcare and your healthcare provider about the status of your prior authorization request.
  •  

  • Be prepared to provide additional information or clarification if requested by Molina Healthcare to facilitate approval.

 

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?

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“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.

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Everything you need is included:

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Your prescription

Premium medication

Overnight shipping

Ongoing support

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 Molina Healthcare Cover Prolia

Explore Molina Healthcare's Prolia coverage, reasons for denial, how to get coverage, cost without insurance, and FAQs in this insightful article.
Curex allergy drops unboxing

Does Molina Healthcare Cover Prolia

 

Coverage of Prolia by Molina Healthcare

 

  • Molina Healthcare may cover Prolia for members who meet specific medical criteria.
  •  

  • Typically, Prolia is approved for postmenopausal women with osteoporosis at high risk of fracture, or patients who have failed other treatments.
  •  

  • A prior authorization is generally required. This means your healthcare provider must submit documentation supporting the medical necessity of Prolia.
  •  

  • Certain conditions such as glucocorticoid-induced osteoporosis or androgen deprivation therapy in men might also be covered depending on plan specifics.
  •  

  • Coverage can vary by state, so it's important to check your specific plan details and consult with your healthcare provider.

 

A weight management program tailored to you

Start with Curex

Why Molina Healthcare Might Deny Prolia Coverage

 

Criteria for Prolia Coverage by Molina Healthcare

 

  • Prolia is covered for the treatment of postmenopausal women with osteoporosis at high risk for fracture. This includes individuals who have a history of osteoporotic fractures or multiple risk factors for fracture.
  •  

  • Candidates for Prolia must have a documented failure or contraindication to other osteoporosis therapies, such as bisphosphonates.
  •  

  • Men with osteoporosis who are at high risk for fracture and have either sustained a fracture or are intolerant to bisphosphonates may also qualify for Prolia coverage.
  •  

  • Patients undergoing androgen deprivation therapy for nonmetastatic prostate cancer, who are at high risk for fracture, are eligible for Prolia coverage if other treatments are not suitable.
  •  

  • Women receiving adjuvant aromatase inhibitor therapy for breast cancer, who are at high risk for fracture, qualify for Prolia when alternative treatments are contraindicated or have failed.
  •  

  • All candidates must show a documented assessment of bone mineral density with established osteoporosis diagnosis to be considered eligible for Prolia under Molina Healthcare’s criteria.
  •  

  • Molina Healthcare requires prior authorization for Prolia, and the request must include clinical documentation supporting the need and specific criteria satisfied for commencement.

 

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

Prolia FAQ

 

Situations Where Prolia Is Not Covered by Molina Healthcare

 

  • Treatment Experimental Status: Prolia may not be covered if it is deemed as experimental or investigational for certain conditions not supported by substantial clinical evidence.
  •  

  • Non-Approved Indications: If Prolia is being prescribed for conditions or diagnoses not expressly approved by the FDA, coverage might be denied.
  •  

  • Dosage and Administration: Prolia use might be excluded if the prescribed dosage or administration does not align with approved guidelines or protocols.
  •  

  • Lack of Prior Authorization: Coverage could be denied if appropriate prior authorization procedures have not been completed and approved before initiating treatment.
  •  

  • Duplicate Therapy: Prolia may not be covered if it is deemed as duplicative therapy that overlaps with other osteoporosis treatments previously covered by the plan.
  •  

  • Non-Compliance with Age Restrictions: If the patient does not meet specific age-related criteria set by Molina Healthcare for coverage of Prolia, the request may be denied.
  •  

  • Absence of Documented Medical Necessity: If there is insufficient medical documentation supporting the necessity of Prolia for the condition being treated, coverage might be denied.

 

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 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.

 

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.

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

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.