Does Medicare cover Prolia in Florida?

What Prolia is used for

Prolia is denosumab, an injection given under the skin once every six months. Its FDA label covers osteoporosis in postmenopausal women and in men at high risk of fracture, osteoporosis caused by steroid medicines, and bone loss from certain hormone treatments for prostate or breast cancer. The label says a health care provider should give it.

This page explains Medicare coverage only. Questions about whether Prolia is right for you belong with your prescriber.

Which part of Medicare covers Prolia

Who pays depends on where and how you get the shot:

• At your doctor's office: Part B, in most cases. Medicare.gov lists injectable osteoporosis drugs among Part B drugs and says Part B covers most injectable drugs when a licensed medical provider gives them. When the office stocks Prolia and gives you the shot, it bills Medicare under Part B.
• At home through home health: Part A or Part B. Medicare covers injectable osteoporosis drugs, and the home health nurse visit to give them, for a woman with osteoporosis who meets the criteria for Medicare home health services, has a fracture a provider certifies is related to postmenopausal osteoporosis, and can't give herself the injection (with no family member or caregiver able and willing to). You pay nothing for the nurse visit.
• Through a Part D plan, when Part B doesn't apply. Part D doesn't pay for a drug Part B covers in your situation, but some Part D plans list Prolia on their formularies for other cases. Ask your doctor's office and your plan how your shot will be billed before your appointment.

Is Prolia on Medicare's negotiated-price list?

No. Prolia is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far: the 10 drugs with negotiated prices since January 1, 2026, the 15 with negotiated prices starting January 1, 2027, and the 15 CMS selected on January 27, 2026, for prices that take effect in 2028.

Biosimilars

On March 5, 2024, FDA approved Jubbonti (denosumab-bbdz) as the first interchangeable biosimilar to Prolia, and has licensed more denosumab biosimilars since; FDA's Purple Book lists them. Under Part B, your doctor's office chooses the product it stocks. If you get it through a Part D plan at a Florida pharmacy, s. 465.0252 lets the pharmacist dispense an FDA-rated interchangeable biosimilar in place of Prolia only if your prescriber hasn't expressed a preference against substitution, and the pharmacist must tell you about the switch.

What you pay for Prolia

When Prolia is billed under Part B:

• Original Medicare: after the yearly Part B deductible, you generally pay 20% of the Medicare-approved amount for the drug. Original Medicare has no yearly out-of-pocket limit.
• Medigap: a Medigap policy can pay some or all of that Part B coinsurance, depending on the plan letter.
• Medicare Advantage: the plan sets its own cost sharing for Part B drugs, and in-network spending is capped by the plan's yearly maximum out-of-pocket limit (no higher than $9,850 in-network in 2027). Plans may require prior authorization or step therapy for Part B drugs.
• Inflation rebates: Medicare.gov notes you may pay lower coinsurance for certain Part B drugs whose prices rise faster than inflation. The list changes every quarter.

CMS publishes the 2027 Part B deductible with its yearly Part A and Part B fact sheet; see Medicare costs in 2027. If a Part D plan covers Prolia instead, the Part D rules apply: your plan's cost sharing, the 2027 Part D out-of-pocket cap of $2,400, the Medicare Prescription Payment Plan and Extra Help. See Extra Help in Florida.

Prolia in Florida: which coverage pays your share

Because Prolia is usually a Part B drug, your medical coverage matters more than your drug plan. With Original Medicare, you can get the shot from any provider who accepts Medicare and pay Part B coinsurance unless Medigap or other coverage pays it. With Medicare Advantage, you use the plan's network and may need prior authorization; every Florida county has Medicare Advantage plans open to everyone for 2027, from 7 in Monroe County to 52 in Hillsborough County. See Florida counties.

Medigap in Florida. Florida has no Medigap birthday rule or yearly switching right, so outside your first Medigap open enrollment or a guaranteed-issue right, a Medigap company can ask health questions. Florida law (s. 627.6741) adds two rights of its own: if your group health coverage ends, you have 2 months to buy a Medigap policy without health questions; and if you're under 65 with Medicare because of a disability or end-stage renal disease, you get a 6-month Medigap open enrollment once you're in Part B. See Medigap in Florida.

Timing a shot every six months. At least 302,773 Floridians in regular Medicare Advantage plans that are leaving or ending must choose new coverage for 2027. If yours is one, choose new coverage by December 31, 2026, and confirm your provider is in the new plan's network so a scheduled dose isn't delayed. You also have a guaranteed right to buy certain Medigap plans for 63 days after the plan ends. See plans ending in 2027.

State Group Insurance retirees. If you keep a State of Florida secondary PPO or HMO plan, it pays after Medicare, and the State says it pays as if you had Part B even if you don't; without Part B you'd pay the roughly 80 percent Medicare would have paid. On one of the State's group Medicare Advantage (MA-PD) plans, Part B drugs follow that plan's rules. See Florida state retirees and Medicare.

Limited income. The Qualified Medicare Beneficiary program (QMB) pays Medicare premiums, deductibles and coinsurance, including the Part B coinsurance on a Prolia shot. Apply through ACCESS Florida (Department of Children and Families) online or at (850) 300-4323. See Medicare Savings Programs in Florida.

Checking your coverage for Prolia

1. Ask the office how it bills Prolia. Most offices that give Prolia bill it to Part B. If the office asks you to get it from a pharmacy instead, ask your Part D plan whether it covers Prolia and what rules apply.
2. Confirm your provider takes your coverage. With Original Medicare, ask whether the office accepts Medicare assignment. With Medicare Advantage, confirm the office is in the plan's network for 2027 and whether prior authorization is needed.
3. Know who pays your coinsurance. Medigap, a Medicare Advantage plan's out-of-pocket limit, State Group Insurance or QMB can cover some or all of your Part B share.
4. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

Sources

• National Library of Medicine — DailyMed: Prolia prescribing information (FDA label, including storage)
• Medicare.gov — Osteoporosis drugs (Part A and Part B, home health nurse visits)
• FDA — FDA approves first interchangeable biosimilars to Prolia and Xgeva (March 2024)
• FDA — Purple Book: licensed biological products, including biosimilars and interchangeables
• Florida Statutes — s. 627.6741, Medigap issuance and open enrollment (including the 2-month window after group coverage ends)
• Medicare.gov — Medicare Savings Programs
• Medicare.gov — Prescription drugs (outpatient): what Part B covers
• Florida Statutes — s. 465.0252, substitution of interchangeable biosimilar products
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program; data file of November 2, 2026)
• CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold, deductible and Extra Help copays)
• Florida DCF — ESS Program Policy Manual, chapter 2000 (MEDS-AD, QMB, SLMB, QI-1)
• Florida Department of Children and Families — Public assistance (ACCESS Florida)
• Florida Division of State Group Insurance — Frequently asked questions: retirees (Medicare, Part D, re-enrollment)
• CMS — Medicare Advantage and Part D Landscape files, 2027 (PDP Region 11: Florida)

Frequently asked questions

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