Question: I changed my insurance for 2026 and I am having trouble with my Prolia shot – what are my options?

Answer: First let me explain what Prolia is for those that may not know. Prolia is a prescription injection, administered by a healthcare professional. It is usually given once every six months. The medication is designed to treat osteoporosis in men and women.

The ‘administered by a healthcare professional’ part of that description is the key part to understanding how it is covered.

There are a number of similar medications to Prolia, like Reclast, but for this article I will focus on Prolia, although the rules are very similar for those alternative medications.

It is important to understand that medications can be covered under our Medical Insurance or our Prescription Drug coverage

When Medicare eligible, medications are covered under Medical Insurance fall under Medicare Part B. When medications are covered under Prescription Drug coverage, that becomes Medicare Part D. Once you are eligible for Medicare, those rules impact the procedure for getting medications more significantly than your insurance prior to Medicare.

The difference in the cost and procedure is significant when you are Medicare eligible.

If your new insurance covers the Prolia injection under Medicare Part B, that means the physician recommends the medication for you, and you agree to take it. Your insurance carrier likely has some prior authorizations to get the shot. The physician’s office orders the medication, it is shipped to their office. Once approved by your insurance carrier, you return to the office and a healthcare professional at that office administers the injection. Your cost will include the office visit, a cost share for the medication (likely 20%) and possibly an administration fee.

If your new insurance covers the Prolia injection under Medicare Part D the procedure is very different. Your physician will recommend the vaccine, and you agree to take it. Your insurance carrier likely has some prior authorizations your physician must complete. Once approved by your insurance carrier, your physician orders it for you through your pharmacy. Once it arrives at the pharmacy, you go and pick it up, bring it to the doctor’s office, and then the healthcare professional administers the injection. Your cost using this process becomes your office visit, the cost share for the medication at the pharmacy, and likely an administration fee, when you return to get the injection. The cost at the pharmacy depends on your plan. Remember that plans can have up to $615 deductible and then a cost share after that.

In thinking about this cost for the medication, a Prolia injection can run between $1,300 and $2,500 per dose. So using the Part B cost structures, that could be as much as $250 to $500 per injection. When thinking about using Part D cost structures, that could be $615 deductible, maybe as much as $825 or more. Each Medicare Part D plan if it covers the Prolia injection has its own cost structures. So you look it up on formulary to determine if it is covered and the tier it is covered in. Once you know that, you can calculate your cost share.

Prolia’s patent expired in February 2025. So, we hope to see some price reductions coming this year and in the years to come. There are some biosimilars that may be available and you could speak to your physician to review your own options.

What I want to stress the most in this discussion is determining how your new insurance covers Prolia.

If you have Medicare + Medicare Supplement + Part D drug plan, the process that you follow to get the medication determines your cost. Does it follow the Part B scenario or the Part D scenario I used earlier. In this situation it would probably be significantly cheaper to use the Part B scenario if you have any choice in the matter. Using this scenario, your costs would be very minimal for the Prolia injection.

If you have a Medicare Advantage Plan (HMO or PPO) it is harder to determine which would cost more. Most Medicare Advantage Plans have a 20% cost share for Part B medications, so following that scenario, you still could be paying hundreds of dollars for the shot. If your Medicare Advantage Plan lists Prolia on its Part D formulary, than it would fall to your Part D scenario reviewed previously.

I hope this helps you to understand your coverage. I would recommend speaking with your provider to determine your situation and the cheapest way to get your Prolia (or similar injection). But it is not only cost, it is also about following the procedures for your new insurance carrier. You may end up calling their customer service department to get direction on how to get this injection covered.

I do wish healthcare was not as complicated as it is becoming…..

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, email editorial@post-journal.com.