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Does Network Health Cover Prolia

Learn about Prolia coverage with Network Health. Explore denial reasons, how-to tips for approval, costs without insurance, and answers to common questions.

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Network Health Coverage for Prolia

Prolia is typically covered under Network Health if it is medically necessary for osteoporosis treatment in postmenopausal women at high risk of fractures or for patients who have failed or are intolerant to other treatments.

Patients may need a prior authorization, demonstrating the medical necessity for receiving Prolia, based on their medical history and the severity of their condition.

Coverage may also apply to men at high risk for fracture due to androgen deprivation therapy for non-metastatic prostate cancer.

Criteria for receiving coverage include a comprehensive assessment conducted by a healthcare provider, detailing the potential benefits and risks associated with Prolia treatment.

Patients need to meet the policy guidelines and criteria set by Network Health, which typically involves submitting documentation from a healthcare provider for evaluation.

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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.

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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.

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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 Network Health

Getting Started with Network Health

Reach out to Network Health by visiting their official website or contacting customer service to inquire about specific plan details that may offer coverage for Prolia.

Register for an online account through the Network Health member portal. This allows you to access personalized information regarding your health plan coverage and benefits.

Check Your Plan Details

Log in to your Network Health account and navigate to the benefits section to review your current medication coverage. Look for any mention of specialty medications like Prolia.

If you're unsure about your coverage, use the benefit inquiry tool or directly contact a Network Health representative for clarification. Ask specifically about the inclusion of Prolia and any necessary prerequisites for coverage.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Prolia. Ensure they are aware of your insurance provider to facilitate proper documentation and authorization processes.

Request that your provider submits any required prior authorization requests to Network Health. This often includes medical records that justify the necessity of Prolia for your condition.

Authorization and Approval Process

Once your healthcare provider submits the prior authorization, follow up with Network Health to track the status. This can often be done through your online account or by contacting customer service.

Ensure all required documentation is submitted correctly and timely. Any missing information can delay the approval process.

Review and Appeals

If your initial coverage request is denied, review the denial letter carefully. Network Health should provide reasons and instructions for how to appeal.

Work with your healthcare provider to gather additional supporting materials to strengthen your case and submit an appeal as instructed by Network Health.

Final Steps

Once approved, confirm coverage details, including copays, deductibles, and any other out-of-pocket costs related to receiving Prolia.

Coordinate with your pharmacy or healthcare facility administering Prolia to ensure seamless acquisition and administration as per Network Health guidelines.

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Does Network Health Cover Prolia

Learn about Prolia coverage with Network Health. Explore denial reasons, how-to tips for approval, costs without insurance, and answers to common questions.

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Is Prolia Covered by Network Health

Network Health Coverage for Prolia

Prolia is typically covered under Network Health if it is medically necessary for osteoporosis treatment in postmenopausal women at high risk of fractures or for patients who have failed or are intolerant to other treatments.

Patients may need a prior authorization, demonstrating the medical necessity for receiving Prolia, based on their medical history and the severity of their condition.

Coverage may also apply to men at high risk for fracture due to androgen deprivation therapy for non-metastatic prostate cancer.

Criteria for receiving coverage include a comprehensive assessment conducted by a healthcare provider, detailing the potential benefits and risks associated with Prolia treatment.

Patients need to meet the policy guidelines and criteria set by Network Health, which typically involves submitting documentation from a healthcare provider for evaluation.

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Network Health's Approved Criteria for Prolia Coverage

Criteria for Prolia Coverage Under Network Health

Prolia is covered for patients who have been diagnosed with osteoporosis, demonstrated by a bone mineral density (BMD) T-score of -2.5 or lower.

Candidates with a history of multiple vertebral fractures or other osteoporosis-related fractures while on other osteoporosis treatment qualify for coverage.

The medication is covered for postmenopausal females at high risk for fracture, or who have failed or are intolerant to other osteoporosis therapies.

Male patients with osteoporosis who are at high risk for fracture, especially those who cannot tolerate or have not had success with other treatments, may be covered.

Coverage is extended to individuals with bone loss associated with certain therapies (such as long-term steroid use) that place the patient at significant risk of a fracture.

Documentation and Submission Requirements

Approval for coverage requires submission of specific documentation, including current BMD test results or relevant medical history supporting osteoporosis diagnosis.

Physicians must provide detailed records of past osteoporosis treatments, including any adverse reactions or intolerances experienced by the patient.

Information regarding the patient’s fracture risks, particularly highlighting those resulting in previous fractures under other therapies, should be readily available.

Additional Considerations for Special Populations

Coverage may include patients undergoing cancer treatment-related bone loss, where Prolia is considered a vital aspect of the overall care plan as noted by a medical professional.

Those with chronic kidney disease (CKD) may be eligible if there is a significant risk of fracture, supported by a physician’s detailed evaluation of bone health and previous treatment outcomes.

Frequency and Continuation of Treatment Coverage

Initial coverage typically includes administration of one dose every six months, with ongoing coverage contingent upon evidence of therapeutic benefit and no significant adverse effects.

Continuation of coverage requires regular follow-up assessments to ascertain drug efficacy and patient tolerance, documented by the healthcare provider.

Why Network Health Might Deny Prolia Coverage

Situations Where Prolia Coverage is Denied

Prolia is prescribed for conditions not specified in the coverage policy that Network Health adheres to, including off-label uses.

The patient does not meet the age-related criteria set by Network Health for Prolia administration.

The patient is not diagnosed with osteoporosis or another qualified condition as recognized by Network Health's coverage guidelines.

Required medical documentation to support the necessity of Prolia treatment is incomplete or insufficient according to Network Health standards.

Treatment with Prolia is not deemed medically necessary by Network Health's evaluation team or contradicts their medical policies.

A cheaper, alternative treatment is recommended and prioritized by Network Health for the condition being treated, making Prolia coverage unavailable.

The prescription is intended for a condition in the early stages where Network Health protocols do not justify the use of Prolia.

The patient has not completed any pre-required steps or alternative treatments that Network Health may specify before authorizing Prolia.

Prolia is being prescribed more frequently than the interval allowed by Network Health’s drug coverage schedule.

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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 Network Health

Getting Started with Network Health

Reach out to Network Health by visiting their official website or contacting customer service to inquire about specific plan details that may offer coverage for Prolia.

Register for an online account through the Network Health member portal. This allows you to access personalized information regarding your health plan coverage and benefits.

Check Your Plan Details

Log in to your Network Health account and navigate to the benefits section to review your current medication coverage. Look for any mention of specialty medications like Prolia.

If you're unsure about your coverage, use the benefit inquiry tool or directly contact a Network Health representative for clarification. Ask specifically about the inclusion of Prolia and any necessary prerequisites for coverage.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Prolia. Ensure they are aware of your insurance provider to facilitate proper documentation and authorization processes.

Request that your provider submits any required prior authorization requests to Network Health. This often includes medical records that justify the necessity of Prolia for your condition.

Authorization and Approval Process

Once your healthcare provider submits the prior authorization, follow up with Network Health to track the status. This can often be done through your online account or by contacting customer service.

Ensure all required documentation is submitted correctly and timely. Any missing information can delay the approval process.

Review and Appeals

If your initial coverage request is denied, review the denial letter carefully. Network Health should provide reasons and instructions for how to appeal.

Work with your healthcare provider to gather additional supporting materials to strengthen your case and submit an appeal as instructed by Network Health.

Final Steps

Once approved, confirm coverage details, including copays, deductibles, and any other out-of-pocket costs related to receiving Prolia.

Coordinate with your pharmacy or healthcare facility administering Prolia to ensure seamless acquisition and administration as per Network Health guidelines.

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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.

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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 Network Health Cover Prolia

Learn about Prolia coverage with Network Health. Explore denial reasons, how-to tips for approval, costs without insurance, and answers to common questions.

Achieve Your Goals Faster with Curex