Back to drug list

Prolia (denosumab)


Billing

Code: J0897

Description: Denosumab injection

Unit: 1 mg

Payment: $23.067

Pay quarter: Q1 2023


Medicare history

Dosage and Frequency

Osteoporosis

• 60mg SQ every 6 months

Calculate drug reimbursement


Total Reimbursement:

$1,467.06

(ASP: $1,384.02, Margin: $83.04)


Code:

J0897

# Units to bill:

60

Prior Authorization

Prior auth criteria for Prolia may include but is not limited to:


1. Bone density measurement by DXA must demonstrate T-score of -2.5 or less at the lumbar spine, total hip, or femoral neck.

2. Patient is at high risk for fracture with a score of 3 or more on the Garvan Fracture Risk Calculator.

3. Patient has failed or is intolerant to other osteoporosis medications.

4. Patient has not received a Prolia injection within the past 12 months.

5. Patient has a documented medical history of osteoporosis and is 18 years of age or older.

6. Patient is not pregnant or lactating.

7. Patient does not have any active infections or are receiving treatments known to interfere with bone metabolism.

8. Patient has not had a history of cancer in the past 5 years, unless approved by the Medical Director.


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

55513-0710-01

Prolia (AMGEN USA, INC.)

60 MG


55513-0730-01

XGEVA (AMGEN USA, INC.)

120 MG



Resources

Drug Enrollment Form

Website