This a new edit to what I wrote earlier: But I am leaving all the stuff I originally wrote in case it helps someone else. It appears from the Medicare site that Part B will not cover Prolia unless you meet the criteria for home health services and have had a bone fracture that meets criteria:
https://www.medicare.gov/coverage/osteoporosis-drugs
Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) help pay for an injectable drug for osteoporosis and visits by a home health nurse to inject the drug if you meet these conditions:
You’re a woman.
You’re eligible for Part B and meet the criteria for Medicare home health services.
You have a bone fracture that a doctor certifies is related to postmenopausal osteoporosis.
Your doctor certifies that you’re unable to learn to give yourself the drug by injection and your family members and/or caregivers are unable and unwilling to give you the drug by injection.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount for the cost of the drug, and the Part B deductible applies. You pay nothing for the home health nurse visit to inject the drug.
This seems pretty definitive that osteoporosis drugs are treated differently than other injectable drugs. They expect you to inject them yourself (it might be different for an infusion for all I know but Prolia is subcutaneous injection).
If I am not reading this right (see below) as to what I found. I did find several places that said you could only get it under Part B if you met the home health care criteria. I am thinking that when people say on some sites it is covered under Part B, they are being technically correct. That is, it can be covered under Part B if you meet that criteria but most people don't. Again, if I am missing something let me know.
Original post and initials edits:
Katsmeow, I think I have good news for you, but you should verify it yourself. My wife takes Prolia. We thought it was under drug plans and bought a higher price plan in 2019 to pay better for it. We found out at time of shot traditional Medicare covers it under traditional Medicare, not the drug plan for us. Depending on your supplement, you may have to pay the deductible if you have not already satisfied it. We were very happy when we found this out and felt silly we paid an extra $45 a month on Part D premium for a year we did not have to. YMMV. Hope this helps.
Dave J is correct. Part D is generally for self-administered drugs. Injections and infused drugs typically fall under Part B when covered by Medicare.
OK I am going to have to research this more. When I mentioned to my doctor, and my concern about insurance he never said it was covered under Part B. That said, he might not realize I am not on Medicare Advantage. He pushed it hard before I went on Medicare and I told him I was doing traditional but he might have forgotten.
I did try to look this up online at Medicare and all I could find about Prolia said that it was only covered for home health care if the patient was unable to give it as an injection. So I assumed from this that it is in fact a self administered injection.
If it is Part B, though, I assume my doctor's office would have to be willing to buy it and administer it to me. What if they won't do that? I once had something for my daughter that was completely covered by insurance if provided by the doctor's office. But if done as a prescription I had to pay a huge co-payment. I called doctor after doctor and they refused to buy it because it was expensive. Is this the same way? Do I have to find out if the doctor will buy it?
So I just need to call the doctor's office and ask them?
EDIT: OK I looked some more at this and I did find several places (not at CMS) that says Prolia or other osteoporosis meds are covered under Part B. Good. But then I found this at CMS itself which seems to limit it:
Injectable and infused drugs: Medicare covers most injectable and infused drugs
given by a licensed medical provider if the drug is considered reasonable and
necessary for treatment and usually isn’t self-administered.
■ Injectable osteoporosis drugs: Medicare covers an injectible drug for women with
osteoporosis who meet the coverage criteria for the Medicare home health benefit
and have a bone fracture that a doctor certifies was related to post-menopausal
osteoporosis. A doctor must certify that the woman is unable to learn to give herself
the drug by injection. The home health nurse or aide won’t be covered to provide the
injection unless family and/or caregivers are unable or unwilling to give the drug by
injection.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/11315-P.pdf
So that seems to say the osteoporosis injections are only covered under Part B if you a bone fracture (I don't) and can't learn to give their own injection. I have never had a bone fracture since having osteoporosis...
I interpreted this to mean that they don't cover it under Part B for shots in the doctor's office at all and only for home health if those criteria is met. But, are they saying that it
is covered in the doctor's office under Part B but
isn't covered under home health unless those criteria are met? Very confusing. Does anyone know?
Just found another place (looks to be insurance related site) which does seem to save you have to meet criteria for home health service, have to have fracture due to osteoporosis and and your family can't be able and willing to do the injection.
Original Medicare Part A and Part B may cover 80 percent of the cost of injectable medications for osteoporosis if you are a post-menopausal female and comply with the criteria for home health services. You must also meet the following requirements to be eligible:
You have a bone fracture due to post-menopausal osteoporosis.
You, or any other family member, is unable or unwilling to administer the injection
and your physician provides certification to back this up.
This seems to make it seem like they treat osteoporosis injections unlike other injections.
Dave J -- Is your wife on traditional Medicare with supplement (that is, not a Medicare Advantage plan?) If so, does she meet the home health criteria mentioned above?
