Prolia (denosumab) is a prescription injection given every six months to treat osteoporosis in postmenopausal women and certain men at high risk of fracture. It works by slowing bone breakdown and helping maintain bone density. Many older adults rely on it to reduce the chance of serious breaks.
Cost is one of the first questions people ask when a doctor recommends Prolia. Medicare coverage makes a big difference in what patients actually pay. Without proper understanding of Part B rules, out-of-pocket expenses can feel unexpectedly high.
This article explains how Medicare handles Prolia, typical costs with and without supplemental plans, and practical ways to lower expenses. The information is for educational purposes only and not medical advice. Always review your specific Medicare plan and talk with your healthcare provider or pharmacist for personalized details.
How Medicare Covers Prolia
Medicare Part B covers Prolia when it is medically necessary and given in a doctor’s office or clinic. It is classified as a physician-administered drug, so it falls under the medical benefit rather than the Part D prescription drug benefit. This distinction matters because Part B has different cost-sharing rules.
Part B usually pays 80% of the Medicare-approved amount after you meet the annual deductible. You are responsible for the remaining 20% coinsurance unless you have supplemental coverage. Prolia is not subject to the Part D donut hole or catastrophic coverage phase.
The Medicare-approved amount for Prolia is based on the average sales price plus a small dispensing fee. This amount changes every quarter and is published by CMS. In most cases, the approved amount is close to the average wholesale price.
Prolia Coverage Requirements
Medicare covers Prolia for:
- Postmenopausal women with osteoporosis and high fracture risk
- Men with osteoporosis and high fracture risk
- Certain patients with glucocorticoid-induced osteoporosis
- People with bone loss from hormone therapy for prostate or breast cancer
Your doctor must document medical necessity and submit proper coding.
Typical Prolia Cost with Medicare Part B
The Medicare-approved amount for one 60 mg dose of Prolia is usually around $1,300 to $1,500 (based on average sales price data). After the Part B deductible is met, Medicare pays about 80% ($1,040–$1,200), leaving you responsible for the 20% coinsurance ($260–$300 per injection).
If you have not met your Part B deductible, you pay the full approved amount until the deductible is satisfied. Once met, the 20% coinsurance applies for the rest of the year. Without Medigap or other supplemental coverage, that 20% is your main out-of-pocket cost.
For two injections per year, the annual coinsurance typically ranges from $520 to $600 after the deductible. This amount can feel significant, especially on a fixed income.
Out-of-Pocket Estimates with Original Medicare
- Annual Part B deductible: $240 (2025 amount, subject to change)
- Coinsurance per injection: ~$260–$300
- Annual total coinsurance (2 doses): ~$520–$600
- Full cost if deductible not met: up to ~$1,300–$1,500 per dose
These are approximate figures based on recent average sales prices.
Medigap (Medicare Supplement) Impact on Prolia Cost
Medigap plans help cover the 20% coinsurance that Original Medicare leaves behind. Plans with full Part B coinsurance coverage (Plans F, G, N, and others) reduce your out-of-pocket cost for Prolia to $0 after the Part B deductible.
Plan G is one of the most popular choices because it covers the 20% coinsurance after the deductible. Many beneficiaries with Plan G pay nothing for Prolia injections once the deductible is met.
Plan N requires small co-pays for office visits but still covers the majority of the Prolia coinsurance. Choosing the right Medigap plan can make Prolia essentially free beyond the deductible.
Medigap Plans and Prolia Coinsurance
- Plan F or G: Usually $0 coinsurance after deductible
- Plan N: Small office-visit co-pay, but coinsurance covered
- No Medigap: You pay the full 20% coinsurance (~$260–$300 per injection)
Medigap premiums vary by plan, location, age, and insurer.
Medicare Advantage (Part C) Coverage for Prolia
Medicare Advantage plans must cover Prolia at least as well as Original Medicare. Most MA plans treat Prolia the same way: covered under medical benefits with the plan’s coinsurance or co-pay.
Some Medicare Advantage plans have lower out-of-pocket maximums than Original Medicare without supplemental coverage. Once you reach the plan’s annual out-of-pocket limit, the plan covers 100% of additional costs, including Prolia.
Other MA plans may require prior authorization or have step therapy rules. Always check your specific plan’s evidence of coverage or call the plan directly.
Medicare Advantage vs Original Medicare for Prolia
- Many MA plans have lower out-of-pocket maximums
- Some require referrals or prior authorization
- Co-pays or coinsurance vary by plan
- Out-of-pocket maximum protects against high costs
Review your plan documents or call member services for exact rules.
Manufacturer and Patient Assistance Programs
Amgen, the maker of Prolia, offers the Prolia Co-Pay Program for eligible commercially insured patients. It reduces out-of-pocket costs to as low as $25 per injection. This program does not apply to Medicare beneficiaries due to federal rules.
For Medicare patients, Amgen Safety Net Foundation provides free Prolia to qualifying low-income individuals without sufficient insurance coverage. Eligibility is based on household income and lack of other resources.
Other nonprofits and state programs sometimes assist with Prolia costs. Local Area Agencies on Aging or social workers can help identify available resources.
Steps to Explore Assistance
- Check Amgen Safety Net Foundation eligibility online
- Contact your doctor’s office for help with applications
- Ask about local charity care or state programs
- Use national prescription assistance directories
These programs help many people who qualify.
Ways to Lower Out-of-Pocket Costs for Prolia
Choose a Medicare Advantage plan with a low out-of-pocket maximum if you expect frequent injections or other medical expenses. Adding a Medigap plan that covers Part B coinsurance eliminates most of the cost after the deductible.
Ask your doctor’s office if they participate in any cost-saving programs or can provide samples. Some clinics help coordinate manufacturer assistance even for Medicare patients in special circumstances.
Shop around for the injection administration fee. Some providers charge less for the office visit and administration than others. This small difference adds up over time.
Practical Tips to Reduce Prolia Expenses
- Confirm coverage and co-pays before each injection
- Apply for assistance programs early
- Choose a Medigap plan with strong Part B coverage
- Ask about lower-cost injection locations
- Keep records of all expenses for tax purposes
These steps help many patients manage the cost more comfortably.
Conclusion
With Medicare, Prolia typically costs patients $260–$300 per injection in coinsurance after the Part B deductible is met, which translates to roughly $520–$600 per year for two doses. Adding a Medigap plan that covers the 20% coinsurance often reduces the out-of-pocket amount to nearly zero after the deductible. Medicare Advantage plans may further limit costs through annual out-of-pocket maximums, while manufacturer and nonprofit assistance programs help qualifying low-income individuals. Understanding your specific plan’s rules, exploring supplemental coverage, and checking for assistance options can make Prolia much more affordable. This article is for informational purposes only and not medical advice—review your Medicare plan details and speak with your healthcare provider or a Medicare counselor for guidance tailored to your coverage and health needs.
FAQ
How much do I pay for Prolia with Original Medicare?
After meeting the Part B deductible, you usually pay 20% coinsurance, which is about $260–$300 per injection. That means roughly $520–$600 per year for two doses.
Does Medicare Advantage cover Prolia the same way?
Most Medicare Advantage plans cover Prolia like Original Medicare, but co-pays, coinsurance, and out-of-pocket maximums vary by plan. Many have lower annual limits than Original Medicare alone.
Will Medigap pay for my Prolia coinsurance?
Yes, Medigap plans that cover Part B coinsurance (such as Plan G or F) typically pay the 20% after the deductible. This can make Prolia cost $0 per injection once the deductible is met.
Is Prolia covered under Medicare Part B or Part D?
Prolia is covered under Part B because it is a physician-administered injection. It is not covered under Part D prescription drug plans.
Can I get help paying for Prolia if I have Medicare?
The Amgen Safety Net Foundation offers free Prolia to qualifying low-income Medicare patients. Contact your doctor’s office or the foundation directly to check eligibility.
How often is Prolia given, and does that affect the cost?
Prolia is injected every six months, so most people receive two doses per year. The annual out-of-pocket cost is roughly double the per-injection amount after the deductible.
Do I have to pay the full Medicare-approved amount for Prolia?
No. Once the Part B deductible is met, you pay only the 20% coinsurance. Medicare pays the remaining 80% of the approved amount.
Are there ways to reduce the cost of Prolia injections?
Adding Medigap coverage, choosing a Medicare Advantage plan with a low out-of-pocket maximum, or applying for assistance programs can significantly lower your costs.
Does the cost of Prolia include the doctor’s office visit?
The Medicare-approved amount covers the drug and administration fee. You may have a separate office visit co-pay or coinsurance depending on your plan.
What should I do if I cannot afford Prolia with Medicare?
Contact your doctor about the Amgen Safety Net Foundation or other assistance programs. Local Area Agencies on Aging and social workers can also help identify resources.
Dr. Usman is a medical content reviewer with 12+ years of experience in healthcare research and patient education. He specializes in evidence-based health information, medications, and chronic health topics. His work is based on trusted medical sources and current clinical guidelines to ensure accuracy, transparency, and reliability. Content reviewed by Dr. Usman is for educational purposes and does not replace professional medical advice.