When submitting the claim, remember to: Bill 60 units of J0897 with administration HCPCS 96372 (Therapeutic prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). J0897 is for 1 mL. Prolia is administered in a single-dose prefilled syringe of 60mg/mL.
Dual eligibility: Medicare Part D is the primary source of drug coverage for “dual eligible” beneficiaries covered under both Medicare and Medicaid. Access is defined as the ability of a patient to obtain Prolia®, although patient OOP cost and insurance requirements may vary.
HCPCS code J0897 should be used to report denosumab (Prolia™, Xgeva™) for claims submitted to the Part A and Part B MAC.
Background. Denosumab has not been previously considered by PBAC for this indication. Denosumab is currently PBS listed for osteoporosis and established post-menopausal osteoporosis.
99% of Medicare Part D patients have access* to Prolia. The average out-of-pocket (OOP) cost for Prolia® through Medicare Part D is $115‡ every 6 months, which equals $19.16 per month.
2.4 The acquisition cost of denosumab is £183 for a 1 ml pre-filled syringe (60 mg per ml solution; excluding VAT, 'MIMS' September 2010 edition), which is equivalent to £366 for 1 year of treatment.
Is this medicine subsidised? This medicine was verified as being available on the PBS (Pharmaceutical Benefits Scheme) on July 1, 2023.
You can only collect PBS medicines from a pharmacy. To collect PBS medicines you need to show your Medicare card when filling your prescription. You won't get a discount for over the counter medicines. You may get PBS medicines at a further discount if you have a concession or health care card.
For further information about the PBS and Safety Net arrangements, ask your pharmacist, contact the PBS Information Line on 1800 020 613 (free call) or visit the Services Australia.
CPT® Code 96401 - Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration - Codify by AAPC.
Drugs that have the ingredients romosozumab-aqqg are billed using HCPCS code J3111, if all existing guidelines for coverage under the home health benefit are met. HCPCS code J311 is defined as 1 mg. Providers should report 1 unit for each 1 mg dose provided during the billing period.
Code. Description. J2506. INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG.
Denosumab belongs to a class of drugs called monoclonal antibodies. It prevents certain cells in the body (osteoclasts) from breaking down bone.
Original Medicare (Part A and Part B) and Medicare Advantage plans (Part C) can cover cortisone injections for pain relief and arthritis.
Prolia® isn't just for women with postmenopausal osteoporosis—it's also an approved treatment for these conditions. Men, don't wait for back pain, height loss, or even a fracture to get serious about male osteoporosis.
How much am I charged for non-PBS items? If your medicine is not listed under the PBS Schedule, you will have to pay full price as a private prescription; it is not subsidised by the Commonwealth. Pharmacies may charge differently for these non-PBS medicines, so you may want to shop around to find the best price.
Medicare subsidises a large number of health services and products. You can use your Medicare card to access medical services, hospital services for public patients, surgical services, prescription medicines, eye tests, pathology tests, imaging and scans.
The Pharmaceutical Benefits Scheme (PBS) is a federal government system that subsidises the cost of some medications. Everyone who has a Medicare card is covered by the PBS and can access PBS-listed medications at a subsidised cost.
INDICATIONS: Treatment of osteoporosis in postmenopausal women to reduce risk of vertebral, non-vertebral and hip fractures. Treatment to increase bone mass in men with osteoporosis at increased risk of fracture. CONTRAINDICATIONS: Hypocalcaemia. Hypersensitivity to denosumab, CHO-derived proteins or any component.
Prolia® is a prescription medicine used to increase bone mass in men with osteoporosis who are at high risk for fracture.
Injectable Drugs Coverage
Medicare Part A or Medicare Part B will pay for a portion of the cost of osteoporosis medications delivered intravenously or by injection. These medications may include ibandronate (Boniva), zoledronic acid (Reclast), denosumab (Prolia) and sometimes calcitonin (Miacalcin).
Prolia, with the generic name Denosumab, is a type of monoclonal antibody, which stops the natural breakdown of bones. Prolia is injected two times per year. It should only be used if other treatment methods have failed or by post-menopausal women who have severe osteoporosis.
How long can I stay on Prolia for? For Prolia to work well at reducing fractures it needs to be taken long term and in one phase 2 clinical trial it has been used safely for up to 8 years with substantial increase in bone density, although most clinical trials are for 3 or 4 years.
Prolia® injection is a brand of denosumab, which treats osteoporosis. Osteoporosis is a condition that weakens your bones, making them more susceptible to fractures. Xgeva® is another brand of denosumab that treats high calcium levels caused by cancer and prevents bone breaks.