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Does Sharp Health Plan Cover Prolia

Learn about Prolia coverage with Sharp Health Plan, reasons for denial, ways to secure coverage, Prolia costs without insurance, and answers to common questions.

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Prolia Coverage by Sharp Health Plan

Sharp Health Plan covers Prolia for treatment of osteoporosis in high-risk patients, particularly postmenopausal women or patients with other high fracture risks.

Prolia is considered medically necessary if other treatments have failed or aren’t suitable due to side effects.

A prior authorization is typically required, involving a physician's assessment and documentation supporting the necessity of the treatment.

Patients may need to demonstrate inadequate response to other osteoporosis medications to qualify.

Coverage might be limited to prescriptions dispensed by specific in-network pharmacies as outlined by the plan.

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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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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 Sharp Health Plan

Verify Insurance Eligibility

Contact Sharp Health Plan directly to verify if your current health plan covers Prolia. This includes checking your specific plan details and understanding any prerequisite conditions or documentation required for coverage.

Review your plan's formulary to confirm that Prolia is included. The formulary is a list of medications covered by the insurance plan, and it will specify any restrictions or prior authorization requirements.

Consult with Your Healthcare Provider

Discuss with your primary healthcare provider to determine whether Prolia is necessary for your treatment. Obtain a prescription along with any required documentation supporting the necessity of this medication.

If the provider determines Prolia is appropriate, request they initiate a prior authorization if necessary. This process involves paperwork where the provider explains the need for the drug to the insurance company.

Complete Prior Authorization

Work with your healthcare provider to complete any prior authorization forms required by Sharp Health Plan. This may involve providing medical records, treatment history, and your current diagnosis.

Ensure that the authorization request is submitted to Sharp Health Plan and follow up regularly to check on its status. The process may take some time, so be proactive in contacting the insurer for updates.

Understand Your Out-of-Pocket Costs

Review your Sharp Health Plan to understand any out-of-pocket costs involved, such as co-pays, deductibles, or coinsurance related to Prolia.

If costs are prohibitive, consider discussing with your healthcare provider about alternative medications or potential financial assistance programs for Prolia patients.

Fill Your Prescription

Once prior authorization is approved, take your Prolia prescription to a pharmacy that is within Sharp Health Plan's network to avoid additional costs.

Ensure the pharmacy verifies coverage with Sharp Health Plan before filling the prescription to confirm that it will be covered under your plan.

Follow Up with Sharp Health Plan and Your Provider

Maintain regular communication with both Sharp Health Plan and your healthcare provider regarding any subsequent doses or renewals of your Prolia prescription.

If any issues arise with coverage, contact your healthcare provider and Sharp Health Plan immediately to resolve them, ensuring continuous treatment with Prolia.

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FAQs

Does Sharp Health Plan Cover Prolia

Learn about Prolia coverage with Sharp Health Plan, reasons for denial, ways to secure coverage, Prolia costs without insurance, and answers to common questions.

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Is Prolia Covered by Sharp Health Plan

Prolia Coverage by Sharp Health Plan

Sharp Health Plan covers Prolia for treatment of osteoporosis in high-risk patients, particularly postmenopausal women or patients with other high fracture risks.

Prolia is considered medically necessary if other treatments have failed or aren’t suitable due to side effects.

A prior authorization is typically required, involving a physician's assessment and documentation supporting the necessity of the treatment.

Patients may need to demonstrate inadequate response to other osteoporosis medications to qualify.

Coverage might be limited to prescriptions dispensed by specific in-network pharmacies as outlined by the plan.

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Sharp Health Plan's Approved Criteria for Prolia Coverage

Eligibility Criteria for Prolia Coverage

**Diagnosis of Osteoporosis**: Patient must have a diagnosis of osteoporosis confirmed through a bone mineral density (BMD) test with T-score indicative of osteoporosis (T-score of -2.5 or lower).

**Postmenopausal Women and Men at High Fracture Risk**: Coverage is provided for postmenopausal women and men who are at high risk for fractures.

**Documented History of Osteoporotic Fracture**: Patients with a history of osteoporotic fractures are eligible.

**Failure or Contraindication to Other Osteoporosis Therapies**: Prolia is covered for patients who have tried and failed or have a medical contraindication to other osteoporosis treatments such as bisphosphonates.

**Evaluation by Healthcare Professional**: Patient must be evaluated by a healthcare professional who deems Prolia necessary based on their clinical judgment.

Required Documentation

**Medical Records**: Submission of medical records confirming diagnosis, fracture history, and any previous treatments.

**Healthcare Provider Recommendation**: A detailed note or recommendation from the healthcare provider supporting the need for Prolia.

Continuation of Therapy Criteria

**Periodic Review**: Determination of continual coverage is based on periodic review of therapy effectiveness and patient compliance.

**Demonstrated Improvement**: Documentation of improved bone density scans or reduction in fracture rates is favorable for continued coverage.

Administration and Dosing

**Standard Dosing**: Coverage is provided for the standard dosing regimen of one 60 mg subcutaneous injection of Prolia every six months, administered by a healthcare professional.

Why Sharp Health Plan Might Deny Prolia Coverage

Circumstances Where Prolia May Not Be Covered

Prolia is being prescribed for a condition not listed in the approved drug formulary of Sharp Health Plan.

The patient's medical records do not demonstrate sufficient medical necessity as stipulated by Sharp Health Plan's criteria.

The prescribed dosage or treatment frequency deviates from the established guidelines without adequate justification.

Prolia is being prescribed outside of the licensed indications approved by health authorities, such as off-label use.

The patient has not tried alternative medications that are required by the plan's step therapy protocol before using Prolia.

The prescribing healthcare provider is not within the Sharp Health Plan's network of approved providers.

Coverage requests are missing essential documentation, such as recent lab results or previous treatment records.

The treatment does not adhere to established failure-to-treat criteria, meaning the patient has not had an inadequate response to prior therapies.

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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 Sharp Health Plan

Verify Insurance Eligibility

Contact Sharp Health Plan directly to verify if your current health plan covers Prolia. This includes checking your specific plan details and understanding any prerequisite conditions or documentation required for coverage.

Review your plan's formulary to confirm that Prolia is included. The formulary is a list of medications covered by the insurance plan, and it will specify any restrictions or prior authorization requirements.

Consult with Your Healthcare Provider

Discuss with your primary healthcare provider to determine whether Prolia is necessary for your treatment. Obtain a prescription along with any required documentation supporting the necessity of this medication.

If the provider determines Prolia is appropriate, request they initiate a prior authorization if necessary. This process involves paperwork where the provider explains the need for the drug to the insurance company.

Complete Prior Authorization

Work with your healthcare provider to complete any prior authorization forms required by Sharp Health Plan. This may involve providing medical records, treatment history, and your current diagnosis.

Ensure that the authorization request is submitted to Sharp Health Plan and follow up regularly to check on its status. The process may take some time, so be proactive in contacting the insurer for updates.

Understand Your Out-of-Pocket Costs

Review your Sharp Health Plan to understand any out-of-pocket costs involved, such as co-pays, deductibles, or coinsurance related to Prolia.

If costs are prohibitive, consider discussing with your healthcare provider about alternative medications or potential financial assistance programs for Prolia patients.

Fill Your Prescription

Once prior authorization is approved, take your Prolia prescription to a pharmacy that is within Sharp Health Plan's network to avoid additional costs.

Ensure the pharmacy verifies coverage with Sharp Health Plan before filling the prescription to confirm that it will be covered under your plan.

Follow Up with Sharp Health Plan and Your Provider

Maintain regular communication with both Sharp Health Plan and your healthcare provider regarding any subsequent doses or renewals of your Prolia prescription.

If any issues arise with coverage, contact your healthcare provider and Sharp Health Plan immediately to resolve them, ensuring continuous treatment with 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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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 Sharp Health Plan Cover Prolia

Learn about Prolia coverage with Sharp Health Plan, reasons for denial, ways to secure coverage, Prolia costs without insurance, and answers to common questions.

Achieve Your Goals Faster with Curex