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Medicare Coverage for Osteoporosis Drug Prolia

To have Prolia drug coverage, your Medicare Advantage plan must include drug coverage. Furthermore, to enroll in a Medicare Advantage plan, you must have both Medicare Part A and Part B. However, if you have original Medicare, you can get a standalone Part D drug plan by having Medicare Part A or Part B.

Medicare Eligibility for Osteoporosis Drugs

To be Medicare-eligible for osteoporosis drugs, you must meet the following conditions:

  • Be a woman

  • Have a bone fracture that a doctor certifies is related to postmenopausal osteoporosis

To be eligible for Medicare home health services, you must meet the following conditions:

  • You have Medicare Part B

  • Your doctor certifies you are unable to learn to give yourself the drug by injection

  • A family member or caregiver is unable and unwilling to give you the drug by injection

Furthermore, a doctor must certify you are homebound and do not need more than part-time or intermittent skilled nursing care. If you meet the above conditions, Medicare does cover Prolia injections by a home health nurse.

Common Questions about Osteoporosis

What is osteoporosis?

According to the Mayo Clinic , osteoporosis “causes your bones to become weak and brittle.” Osteoporosis is most commonly found in white senior women who are past menopause. CDC.gov  data shows 24.5 percent of women 65 years old and over have osteoporosis of the femur, neck, or lumbar spine. Thus, 1 in 5 female seniors has osteoporosis.

You may have osteoporosis if you have the following signs and symptoms:

  • Back pain caused by a fractured vertebra

  • Loss of height over time

  • A stooped (bent over) posture

  • A bone that breaks easier than expected

How do you prevent osteoporosis?

The Mayo Clinic says, “good nutrition and regular exercise are essential for keeping your bones healthy throughout your life.” To maintain healthy bones, women age 50 and over need 1200 milligrams of calcium (Ca). The following foods are good sources of calcium (per 100 grams):

  • Dairy products such as cheddar cheese (707mg)

  • Silk soy milk (450mg per cup)

  • Canned sardines with bones (382mg)

If you consume less than 1200mg per day, please consider taking a calcium supplement. However, consuming too much calcium is associated with kidney stones. Furthermore, too much supplemental calcium may increase your risk of heart disease. Thus, please limit your calcium intake to 2,000mg per day.

In addition to calcium, you also need Vitamin D for healthy bones. So how much vitamin D do seniors need? According to the fact sheet at NIH.gov , Vitamin D helps your body absorb calcium. By consuming recommended amounts of calcium and vitamin D, you can help prevent osteoporosis. Adults 19-70 need 15 micrograms (mcg) or 600 International Units (IU). However, seniors over the age of 70 need 20mcg or 800 IU.

Medicare costs for Prolia injections

Your Medicare costs will depend on who administers your Prolia injection and your Medicare plan. If you have Original Medicare and self-administer Prolia inject, your Part D drug plan covers the cost.

However, if you have Original Medicare and a home health nurse administers your Prolia injections, Part B does cover 80% of the drug cost. Consequently, you pay the annual Part B deductible, monthly Part B premium, and 20% of the drug price.

Medicare Advantage Prolia costs

If you have a Medicare Advantage (MA) plan without drug coverage and self-administer Prolia injections, your drug costs are not covered. Consequently, the list price you would pay may be $1278. To avoid paying such a high price, we recommend you switch to a Medicare Advantage plan with drug coverage. Otherwise, have a home health nurse administer Prolia. Then your cost is only Medicare Part B deductible, the monthly premium, and your MA plan costs.

However, if you have a Medicare Advantage plan with drug coverage, the costs are similar no matter who administers Prolia injections. For example, you can administer Prolia injections yourself or have a home health nurse do it, and your Medicare costs are about the same. You pay Medicare Part B and your Medicare Advantage plan costs.

Are you at risk for Osteoporosis?

Some medical conditions put you at greater risk for osteoporosis. For example, estrogen deficiency could put you at higher risk for bone loss. Furthermore, if you are diagnosed with primary hyperparathyroidism, your parathyroid gland(s) enlarge, increasing the blood’s calcium levels. As a result, less calcium enters your bones, causing osteoporosis. (Mayo Clinic)

X-rays can show signs of osteoporosis, osteopenia, or vertebral fractures. Also, taking steroid medications can lead to bone loss and cause osteoporosis. For example, long-term use of Prednisone (Glucocorticoids) may result in bone damage. (Osteoporosis.ca )

If you are at risk for osteoporosis, Medicare pays for the costs of bone mass measurements (bone density tests). Every two years, Medicare covers this cost to evaluate your risk of broken bones.

Furthermore, this Medicare-covered test helps your doctor monitor your osteoporosis drug therapy to see if Prolia injections are working. (Medicare.gov )