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Does UPMC Health Plan Cover Prolia

Find out if UPMC covers Prolia, why it might deny coverage, ways to secure approval, and Prolia's cost without insurance in our detailed guide.

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UPMC Health Plan Coverage for Prolia

UPMC Health Plan typically covers Prolia, a medication used for osteoporosis, under specific conditions. Coverage may depend on the specific plan and medical necessity.

Prolia is generally covered for postmenopausal women with osteoporosis at high risk for fracture, or patients who have failed or are intolerant to alternative osteoporosis therapies.

Prior authorization is commonly required, involving proof of medical necessity and documentation showing previous osteoporosis treatment failures or contraindications.

The prescribing doctor must provide a detailed treatment history and a rationale for Prolia usage, showing that the patient meets UPMC's coverage criteria.

Annual or bi-annual re-evaluation might be necessary to continue receiving Prolia under the plan, and the coverage may vary depending on updates in policy.

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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 UPMC Health Plan

Contact UPMC Health Plan Customer Service

Reach out to UPMC Health Plan customer service by calling the number on the back of your member ID card.
Inquire about your current plan coverage and ask if Prolia is covered under your policy.
Request information regarding any prior authorization requirements for Prolia.

Consult with Your Healthcare Provider

Discuss your need for Prolia with your healthcare provider.
Obtain a prescription for Prolia from your doctor if they determine it is medically necessary.
Ensure your provider is aware that prior authorization might be needed.

Submit Prior Authorization Request

Work closely with your healthcare provider to submit a prior authorization request to UPMC Health Plan for Prolia.
Ensure that your doctor provides all necessary medical documentation to support the request.
Your provider can submit the request online or via fax, depending on the preferred method by UPMC Health Plan.

Follow Up on Authorization Status

Stay in touch with your healthcare provider to monitor the status of the prior authorization.
Contact UPMC Health Plan for updates if there is a delay in response.
Prepare to provide additional information if requested by UPMC Health Plan.

Review Coverage Determination

Once approval is received, review the coverage determination letter from UPMC Health Plan.
Confirm the details of your coverage, including out-of-pocket costs and where you can get the medication.
Contact UPMC Health Plan if there are any discrepancies or questions about the coverage explained in the letter.

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FAQs

Does UPMC Health Plan Cover Prolia

Find out if UPMC covers Prolia, why it might deny coverage, ways to secure approval, and Prolia's cost without insurance in our detailed guide.

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Is Prolia Covered by UPMC Health Plan

UPMC Health Plan Coverage for Prolia

UPMC Health Plan typically covers Prolia, a medication used for osteoporosis, under specific conditions. Coverage may depend on the specific plan and medical necessity.

Prolia is generally covered for postmenopausal women with osteoporosis at high risk for fracture, or patients who have failed or are intolerant to alternative osteoporosis therapies.

Prior authorization is commonly required, involving proof of medical necessity and documentation showing previous osteoporosis treatment failures or contraindications.

The prescribing doctor must provide a detailed treatment history and a rationale for Prolia usage, showing that the patient meets UPMC's coverage criteria.

Annual or bi-annual re-evaluation might be necessary to continue receiving Prolia under the plan, and the coverage may vary depending on updates in policy.

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UPMC Health Plan's Approved Criteria for Prolia Coverage

Coverage Criteria for Prolia

Prolia is covered for individuals diagnosed with osteoporosis who are at high risk for fracture. This includes postmenopausal women and men who have not responded to other osteoporosis treatments.

Candidates should have low bone mass according to bone mineral density tests, indicating T-scores consistent with osteoporosis or specific conditions indicating a high fracture probability.

The patient must have a history of osteoporotic fracture or multiple risk factors for fracture, which may include advanced age or prolonged glucocorticoid therapy.

Individuals with contraindications or intolerance to oral bisphosphonates, the usual first-line treatment, are eligible for Prolia coverage.

Additional Indications

Coverage includes patients undergoing hormone deprivation therapy for cancer treatment, as these therapies can result in bone loss. Prolia is authorized to prevent fractures in this setting.

Individuals with reduced kidney function, who cannot safely use bisphosphonates, may receive coverage for Prolia as an alternative treatment.

Duration and Renewal Criteria

The initial approval period typically extends for six months, with subsequent renewals available based on evidence of continued necessity.

Renewal requires demonstration of benefits, evidenced by stability or improvement in bone mineral density tests or a decrease in the incidence of fractures.

Physician Preauthorization

Prior authorization from a healthcare professional is required to ensure appropriate application of Prolia and adherence to recommended treatment intervals and dosages.

Why UPMC Health Plan Might Deny Prolia Coverage

Situations and Criteria for Denial of Prolia Coverage by UPMC Health Plan

Prolia is not covered if it is prescribed for non-FDA approved uses by physicians.

The patient does not meet the medical necessity criteria set by UPMC Health Plan for Prolia use.

Lack of documentation supporting the diagnosis related to osteoporosis or related conditions.

Alternative and less costly treatment options have not been considered or tried prior to administering Prolia.

Prolia is prescribed for conditions that are not included in UPMC's policy guidelines for treatment with this medication.

The patient does not have a confirmed diagnosis of high risk of fracture as defined by UPMC Health Plan criteria.

There is an absence of prior authorization or failure to adhere to the prior authorization process specific to biologic therapies like Prolia.

The patient has switched providers during treatment and the new provider’s plan does not include Prolia under its formulary or benefits.

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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 UPMC Health Plan

Contact UPMC Health Plan Customer Service

Reach out to UPMC Health Plan customer service by calling the number on the back of your member ID card.
Inquire about your current plan coverage and ask if Prolia is covered under your policy.
Request information regarding any prior authorization requirements for Prolia.

Consult with Your Healthcare Provider

Discuss your need for Prolia with your healthcare provider.
Obtain a prescription for Prolia from your doctor if they determine it is medically necessary.
Ensure your provider is aware that prior authorization might be needed.

Submit Prior Authorization Request

Work closely with your healthcare provider to submit a prior authorization request to UPMC Health Plan for Prolia.
Ensure that your doctor provides all necessary medical documentation to support the request.
Your provider can submit the request online or via fax, depending on the preferred method by UPMC Health Plan.

Follow Up on Authorization Status

Stay in touch with your healthcare provider to monitor the status of the prior authorization.
Contact UPMC Health Plan for updates if there is a delay in response.
Prepare to provide additional information if requested by UPMC Health Plan.

Review Coverage Determination

Once approval is received, review the coverage determination letter from UPMC Health Plan.
Confirm the details of your coverage, including out-of-pocket costs and where you can get the medication.
Contact UPMC Health Plan if there are any discrepancies or questions about the coverage explained in the letter.

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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.

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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 UPMC Health Plan Cover Prolia

Find out if UPMC covers Prolia, why it might deny coverage, ways to secure approval, and Prolia's cost without insurance in our detailed guide.

Achieve Your Goals Faster with Curex