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Does Regence Cover Prolia

Explore Regence's Prolia coverage, reasons for denial, steps to secure it, cost without insurance, and FAQs. Get clear answers to aid your healthcare journey.

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Regence Coverage for Prolia

Prolia, a medication for osteoporosis, may be covered by Regence, depending on plan specifics and medical necessity.

Insurance coverage can vary based on patient diagnosis, prescribed treatment plan, and compliance with Regence guidelines.

Criteria for Coverage

Diagnosis of osteoporosis or other qualifying conditions as determined by a healthcare provider.

Documentation of the necessity for Prolia, usually after evaluation of other treatment options.

Authorization may require demonstrating inadequate response or contraindication to other osteoporosis medications.

Basic Rules

Consult with your healthcare provider to ensure proper documentation aligns with Regence's policy guidelines.

Pre-authorization from Regence might be necessary before Prolia is administered.

Contact Regence directly for specific policy details and individual plan coverage variations.

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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 Regence

Verify Your Regence Plan Coverage

Log into your Regence member account to access your plan details.

Consult your plan's evidence of coverage or summary of benefits to determine if Prolia (denosumab) is included under your pharmacy or medical benefits.

If you cannot find this information online, consider calling Regence customer service using the number on your insurance card for confirmation.

Consult with Your Healthcare Provider

Discuss your need for Prolia with your healthcare provider. They should be familiar with your treatment plan and the need for this medication.

Your healthcare provider can help determine if there are any specific coverage guidelines or prior authorization requirements for Prolia under Regence.

Get a Prescription from Your Healthcare Provider

Request a prescription for Prolia from your healthcare provider. Make sure they provide any necessary documentation to support the need for this specific medication.

This documentation can include medical records, test results, and a letter of medical necessity, if required.

Check for Prior Authorization Requirements

Review your Regence plan documentation or consult with a customer service representative to determine if prior authorization is required for Prolia.

If needed, work with your healthcare provider to submit a prior authorization request to Regence. This process may include submitting your provider's notes, diagnosis, and reasoning for prescribing Prolia.

Locate an In-Network Pharmacy or Provider

Identify in-network pharmacies or providers that can supply Prolia. This can be done through your Regence member portal or by contacting customer service.

Using an in-network provider ensures that you receive the maximum benefit from your plan and reduces out-of-pocket costs.

Manage Cost and Co-Pay Assistance

Review the co-pay or co-insurance details for Prolia under your specific Regence plan to understand your financial responsibilities.

Consider exploring manufacturer assistance programs or discounts, which may help reduce the cost of Prolia. The manufacturer of Prolia often provides a co-pay assistance program for eligible patients.

Keep Track of Renewal Dates

Prolia is typically administered every six months, so keep track of when your next dose is due.

Ensure that any necessary authorizations or refill requests are submitted in advance to avoid delays in receiving your medication.

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FAQs

Does Regence Cover Prolia

Explore Regence's Prolia coverage, reasons for denial, steps to secure it, cost without insurance, and FAQs. Get clear answers to aid your healthcare journey.

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Is Prolia Covered by Regence

Regence Coverage for Prolia

Prolia, a medication for osteoporosis, may be covered by Regence, depending on plan specifics and medical necessity.

Insurance coverage can vary based on patient diagnosis, prescribed treatment plan, and compliance with Regence guidelines.

Criteria for Coverage

Diagnosis of osteoporosis or other qualifying conditions as determined by a healthcare provider.

Documentation of the necessity for Prolia, usually after evaluation of other treatment options.

Authorization may require demonstrating inadequate response or contraindication to other osteoporosis medications.

Basic Rules

Consult with your healthcare provider to ensure proper documentation aligns with Regence's policy guidelines.

Pre-authorization from Regence might be necessary before Prolia is administered.

Contact Regence directly for specific policy details and individual plan coverage variations.

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Regence's Approved Criteria for Prolia Coverage

Medically Necessary Criteria for Prolia Coverage

Individuals must be diagnosed with osteoporosis in postmenopausal women who are at high risk for fracture, as defined by the healthcare provider based on clinical assessment or established guidelines.

Patients must have a history of treatment failure or contraindication to other osteoporosis therapies, such as bisphosphonates, or oral medications not yielding the desired outcome.

The diagnosis and high fracture risk may also be supported by a bone mineral density (BMD) T-score of -2.5 or lower, particularly in the lumbar spine or total hip.

Patients with multiple risk factors for fracture, including a high probability of fracture per fracture risk assessment tools, align with coverage criteria.

Specific Patient Groups Meeting Criteria

Men with osteoporosis who are at high risk for fracture and have demonstrated intolerance or inadequate response to other osteoporosis treatments.

Individuals receiving androgen deprivation therapy (ADT) for prostate cancer who have increased fracture risk.

Patients undergoing adjuvant aromatase inhibitor therapy for breast cancer, which contributes to an increased risk of bone loss and fractures.

Approval Based on Healthcare Provider Documentation

Documentation must include a comprehensive assessment of the patient's osteoporosis status and risk factor profile, demonstrating the high risk for fracture and unsuitability or failure of prior osteoporosis therapies.

Regular updates and re-assessment by a healthcare provider are required to maintain coverage, ensuring the ongoing high-risk status and the necessity of Prolia as a treatment.

Why Regence Might Deny Prolia Coverage

Reasons for Denial of Prolia Coverage by Regence

Prolia is not covered if the patient does not meet the criteria of having a high risk of fractures due to osteoporosis.

Coverage is denied when Prolia is used for off-label indications not approved by the Food and Drug Administration (FDA).

Regence will refuse coverage if there is inadequate trial or contraindication of other osteoporosis medications, such as bisphosphonates.

Prolia is not covered when the patient is undergoing treatment for conditions that do not warrant its use according to evidence-based guidelines provided by Regence.

Coverage might be denied if the required pre-authorization process has not been properly followed.

Prolia is not covered if duplicate therapy, such as using it in conjunction with another biologic medication for osteoporosis, is identified.

Regence does not cover Prolia if there is insufficient documentation to prove the necessity of this specific treatment over alternative measures.

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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 Regence

Verify Your Regence Plan Coverage

Log into your Regence member account to access your plan details.

Consult your plan's evidence of coverage or summary of benefits to determine if Prolia (denosumab) is included under your pharmacy or medical benefits.

If you cannot find this information online, consider calling Regence customer service using the number on your insurance card for confirmation.

Consult with Your Healthcare Provider

Discuss your need for Prolia with your healthcare provider. They should be familiar with your treatment plan and the need for this medication.

Your healthcare provider can help determine if there are any specific coverage guidelines or prior authorization requirements for Prolia under Regence.

Get a Prescription from Your Healthcare Provider

Request a prescription for Prolia from your healthcare provider. Make sure they provide any necessary documentation to support the need for this specific medication.

This documentation can include medical records, test results, and a letter of medical necessity, if required.

Check for Prior Authorization Requirements

Review your Regence plan documentation or consult with a customer service representative to determine if prior authorization is required for Prolia.

If needed, work with your healthcare provider to submit a prior authorization request to Regence. This process may include submitting your provider's notes, diagnosis, and reasoning for prescribing Prolia.

Locate an In-Network Pharmacy or Provider

Identify in-network pharmacies or providers that can supply Prolia. This can be done through your Regence member portal or by contacting customer service.

Using an in-network provider ensures that you receive the maximum benefit from your plan and reduces out-of-pocket costs.

Manage Cost and Co-Pay Assistance

Review the co-pay or co-insurance details for Prolia under your specific Regence plan to understand your financial responsibilities.

Consider exploring manufacturer assistance programs or discounts, which may help reduce the cost of Prolia. The manufacturer of Prolia often provides a co-pay assistance program for eligible patients.

Keep Track of Renewal Dates

Prolia is typically administered every six months, so keep track of when your next dose is due.

Ensure that any necessary authorizations or refill requests are submitted in advance to avoid delays in receiving your medication.

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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.

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 Regence Cover Prolia

Explore Regence's Prolia coverage, reasons for denial, steps to secure it, cost without insurance, and FAQs. Get clear answers to aid your healthcare journey.

Achieve Your Goals Faster with Curex