Does Medicare Cover Prolia? 

Bone health can be a vital part of maintaining overall health, but it can sometimes be overlooked. Most people don’t think about their bones until a problem pops up, but by that point, a serious bone health issue may exist. Both osteoporosis and bone cancer (bone neoplasm) are threats that can weaken bones and cause them to become brittle and frail. This ultimately leads to an increased potential for breakage and internal injuries as well as the loss of mobility.

How do bone problems form?

Many individuals experience a loss of bone density with age, but conditions like osteoporosis and bone cancer accelerate this process. Diet affects bone loss and can be a contributing factor in the development of osteoporosis. Not getting enough calcium or being unable to properly process calcium can lead to a deficiency that can add to bone loss.

Additionally, changes in hormone production can lead to osteoporosis. For women, the demographic most affected by osteoporosis, a lack of estrogen following menopause is highly correlated to the development of the disease. This condition can also affect men, however, as low levels of testosterone may contribute to the development of osteoporosis.

Bone cancer can occur due to genetic factors, but it may also be attributed to improper healing after a bone injury. For this reason, treating osteoporosis is crucial since this condition can make bones more susceptible to breakage and the development of neoplasms.

Treating osteoporosis

Treating osteoporosis will come down to the cause and extent of the condition. For some individuals, lifestyle adjustments can help to slow the progression of the disease. For others, prescription medications like Prolia may help to reduce bone loss and even lead to an increase in bone mass and density.

What is Prolia?

Prolia (denosumab) is a prescription medication produced by Amgen. It is prescribed primarily to address osteoporosis and other conditions that lead to bone loss. Prolia works by affecting certain proteins in the body responsible for breaking down bone tissue. In combination with other therapies and lifestyle changes, Prolia has been shown to slow the progression of bone loss due to osteoporosis while also demonstrating the ability to allow bone tissue to become stronger under the right conditions.

Does Medicare cover Prolia?

Original Medicare benefits usually cover prescription medications through Medicare Part D. All Part D plans include a formulary that lists covered medications along with exclusions, restrictions and limitations. If you carry Medicare Part D coverage, you will want to consult with your formulary to see your coverage options for Prolia.

If you are administered Prolia while admitted to a hospital or skilled nursing facility, Medicare coverage under Part A applies instead. Medicare Part A covers inpatient treatment for up to 60 days in each benefit period. Beyond 60 days, Medicare recipients can receive discounted coverage for an additional 30 days. If inpatient care is required beyond 90 days, Medicare coverage can continue at the lifetime reserve day rate if you have and use lifetime reserve days.

Medicare Advantage and Prolia coverage

Medicare Advantage plans that include prescription drug coverage may also cover Prolia. Medicare Advantage plans may include additional benefits not found under Original Medicare like nutritional support for osteoporosis and bone cancer or access to exercise classes specifically designed for individuals with bone health concerns. For more information, you’re encouraged to contact your plan provider directly to review your options.

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