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Does UnitedHealthcare Cover Prolia

Explore why UnitedHealthcare might deny Prolia, how to secure coverage, Prolia costs without insurance, and get answers to common Prolia questions in our guide.

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Coverage for Prolia

UnitedHealthcare may cover Prolia for patients with osteoporosis who are at high risk for fracture.

Coverage typically requires FDA approval and medical necessity as evaluated by a healthcare provider.

Criteria for Coverage

Patients must generally have a diagnosis of osteoporosis, confirmed by a bone mineral density test.

Documentation of previous fracture or evidence of high risk for fracture is often required.

Basic Rules

Pre-authorization might be necessary before filling the prescription, ensuring it aligns with UnitedHealthcare's prescribed guidelines.

The drug is usually covered under the prescription drug plan, but specifics can vary based on the individual's insurance policy.

Regular follow-ups and documentation by the healthcare provider may be required to maintain coverage benefits.

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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 UnitedHealthcare

Understand UnitedHealthcare's Drug Coverage Policies

Visit the UnitedHealthcare website and navigate to their pharmacy benefits section to review their drug coverage policies. You will want to understand how they categorize drugs like Prolia under their formulary.
Ensure Prolia is listed on their Drug List (also called a Formulary) by using their online search tool. You may need to input your specific plan details to get accurate information.

Consult with Your Healthcare Provider

Discuss with your healthcare provider about the medical necessity of Prolia for your condition. They will need to provide a prescription and may need to complete a specific form to demonstrate necessity.
Request your healthcare provider to write a detailed letter explaining why Prolia is the best treatment option for your condition, which can be useful if a prior authorization is needed.

Check Plan Specifics

Log into your UnitedHealthcare online account or call customer service to confirm your coverage specifics for Prolia, including co-pays, deductibles, and any prior authorization requirements.
Be aware of any step therapy requirements, which may require trying other medications before Prolia is approved for coverage.

Gather Required Documentation

Compile all necessary documentation, including your prescription, healthcare provider's letter, and any previous treatments or diagnostic results that support the need for Prolia.

Submit a Prior Authorization Request

If needed, have your healthcare provider submit a prior authorization request to UnitedHealthcare. This process typically involves providing the documentation gathered on your behalf.
Ensure that all forms and information required by UnitedHealthcare are correctly filled out and submitted to avoid delays in processing.

Contact UnitedHealthcare for Confirmation

After submitting all required documents, follow up with UnitedHealthcare to confirm the receipt and status of your request for Prolia coverage.
Ask about any possible next steps or additional information that might be needed to expedite the process.

Appeals and Further Action

If the initial request is denied, review the denial letter carefully to understand the reason and follow UnitedHealthcare's appeals process. This may involve submitting additional documentation or having your healthcare provider provide further justification.
Consider working with a patient advocate or legal advisor if you encounter persistent difficulties securing coverage for Prolia.

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FAQs

Does UnitedHealthcare Cover Prolia

Explore why UnitedHealthcare might deny Prolia, how to secure coverage, Prolia costs without insurance, and get answers to common Prolia questions in our guide.

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Is Prolia Covered by UnitedHealthcare

Coverage for Prolia

UnitedHealthcare may cover Prolia for patients with osteoporosis who are at high risk for fracture.

Coverage typically requires FDA approval and medical necessity as evaluated by a healthcare provider.

Criteria for Coverage

Patients must generally have a diagnosis of osteoporosis, confirmed by a bone mineral density test.

Documentation of previous fracture or evidence of high risk for fracture is often required.

Basic Rules

Pre-authorization might be necessary before filling the prescription, ensuring it aligns with UnitedHealthcare's prescribed guidelines.

The drug is usually covered under the prescription drug plan, but specifics can vary based on the individual's insurance policy.

Regular follow-ups and documentation by the healthcare provider may be required to maintain coverage benefits.

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UnitedHealthcare's Approved Criteria for Prolia Coverage

Eligibility for Prolia Coverage by UnitedHealthcare

Member must have a documented diagnosis of osteoporosis, especially in the setting of postmenopausal women or men at high risk for fractures.

Consideration for coverage is given if there's a history of osteoporotic fracture or multiple risk factors for fracture.

Indications validate Prolia as necessary when the patient has either failed or is intolerant to other osteoporosis treatments, such as bisphosphonates.

Clinical Documentation Requirements

Bone Mineral Density (BMD) test results indicating a T-score of -2.5 or lower, confirming osteoporosis diagnosis.

Detailed medical records illustrating previous osteoporosis treatments and the reasons for discontinuation, if applicable.

Comprehensive list of fracture history, including sites, dates, and treatments undertaken for each.

Approval Criteria for Special Populations

Patients with chronic kidney disease (CKD) requiring dialysis, who are at high risk for fracture, may be eligible.

Individuals with a diagnosis of glucocorticoid-induced osteoporosis must display reduced BMD under prolonged glucocorticoid use.

Circumstances encompassing hormone deprivation in cancer treatment, particularly in prostate and breast cancer cases, qualify for Prolia use.

Review and Renewal Consideration

Continuation of therapy coverage necessitates submission of updated medical records demonstrating treatment efficacy, such as improved BMD scores or reduced fracture incidents.

Annual review for treatment renewal will assess the necessity based on current clinical status and ongoing risk evaluation.

Why UnitedHealthcare Might Deny Prolia Coverage

Reasons for Denial of Prolia Coverage by UnitedHealthcare

**Absence of Required Diagnosis**: UnitedHealthcare does not cover Prolia if the patient lacks a diagnosis of osteoporosis in postmenopausal women at high risk for fracture, or for men with osteoporosis who are at high risk for fracture.

**Inadequate Prior Treatment**: If a patient has not tried and failed, or had an inadequate response to previous osteoporosis treatments such as bisphosphonates, UnitedHealthcare may deny coverage for Prolia.

**Lack of Clinical Justification**: Coverage can be denied if there is an absence of detailed clinical documentation demonstrating that Prolia is medically necessary based on the patient's health condition and history.

**Non-Compliance with Monitoring Requirements**: UnitedHealthcare might deny coverage if there is no plan or evidence for appropriate monitoring of calcium levels, as Prolia can cause hypocalcemia.

**Non-Authorization**: If prior authorization is not obtained before starting Prolia treatment, it might lead to a denial of coverage by UnitedHealthcare.

**Excluded Insurance Plans**: Some specific UnitedHealthcare plans might have exclusions that do not cover certain medications like Prolia, resulting in denial of coverage.

**Use in Non-Approved Conditions**: Prolia may be denied if used for an indication not formally approved, such as non-osteoporotic conditions, unless there is significant documentation supporting its use as necessary.

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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 UnitedHealthcare

Understand UnitedHealthcare's Drug Coverage Policies

Visit the UnitedHealthcare website and navigate to their pharmacy benefits section to review their drug coverage policies. You will want to understand how they categorize drugs like Prolia under their formulary.
Ensure Prolia is listed on their Drug List (also called a Formulary) by using their online search tool. You may need to input your specific plan details to get accurate information.

Consult with Your Healthcare Provider

Discuss with your healthcare provider about the medical necessity of Prolia for your condition. They will need to provide a prescription and may need to complete a specific form to demonstrate necessity.
Request your healthcare provider to write a detailed letter explaining why Prolia is the best treatment option for your condition, which can be useful if a prior authorization is needed.

Check Plan Specifics

Log into your UnitedHealthcare online account or call customer service to confirm your coverage specifics for Prolia, including co-pays, deductibles, and any prior authorization requirements.
Be aware of any step therapy requirements, which may require trying other medications before Prolia is approved for coverage.

Gather Required Documentation

Compile all necessary documentation, including your prescription, healthcare provider's letter, and any previous treatments or diagnostic results that support the need for Prolia.

Submit a Prior Authorization Request

If needed, have your healthcare provider submit a prior authorization request to UnitedHealthcare. This process typically involves providing the documentation gathered on your behalf.
Ensure that all forms and information required by UnitedHealthcare are correctly filled out and submitted to avoid delays in processing.

Contact UnitedHealthcare for Confirmation

After submitting all required documents, follow up with UnitedHealthcare to confirm the receipt and status of your request for Prolia coverage.
Ask about any possible next steps or additional information that might be needed to expedite the process.

Appeals and Further Action

If the initial request is denied, review the denial letter carefully to understand the reason and follow UnitedHealthcare's appeals process. This may involve submitting additional documentation or having your healthcare provider provide further justification.
Consider working with a patient advocate or legal advisor if you encounter persistent difficulties securing coverage for 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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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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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.

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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 UnitedHealthcare Cover Prolia

Explore why UnitedHealthcare might deny Prolia, how to secure coverage, Prolia costs without insurance, and get answers to common Prolia questions in our guide.

Achieve Your Goals Faster with Curex