Medicare Coverage for Osteoporosis
Osteoporosis is a condition that causes your bones to become brittle and weak. Medicare covers bone density tests, which can help your doctor diagnose you with osteoporosis and assess how well you respond to medications. Medicare drug plans also cover many medications used to treat osteoporosis.
Medicare Coverage of Bone Mass Density Tests
Medicare covers a bone mass screening test, or bone density test, once every 24 months — or more often if medically necessary — when you meet certain criteria.
Bone density tests establish a formal diagnosis of osteoporosis. They can also assess the efficiency of osteoporosis drug therapy by identifying your bone mass and quality.
Qualifying Medicare beneficiaries pay nothing for bone mass tests.
- You’re a woman whose doctor determines you’re at risk for osteoporosis.
- Your X-rays show possible osteoporosis.
- You’re taking prednisone or steroid-type drugs, or plan to begin these treatments soon.
- You’ve been diagnosed with primary hyperparathyroidism.
- You’re being monitored to see if your osteoporosis drug therapy is working.
There are several different procedures your doctor may use to test your bone density.
- Dual energy X-ray absorptiometry (DXA)
- Radiographic absorptiometry (RA)
- Bone sonometry (ultrasound)
- Single energy X-ray absorptiometry (SEXA)
- Quantitative computed tomography (QCT)
While these preventative services are free for Medicare beneficiaries who qualify, research shows that bone mass tests are often underutilized.
According to a 2019 report commissioned by the National Osteoporosis Foundation, 2 million Medicare recipients suffered fractures in 2015.
But only 9 percent of those beneficiaries had been screened for osteoporosis within six months of sustaining their fracture.
Medicare Coverage of Osteoporosis Medications
Many medications available today can slow the rate of bone loss and, in some cases, even rebuild bone strength.
Osteoporosis medications include oral drugs such as tablets and liquids. You may also be prescribed injectable drugs that you receive at your doctor’s office or administer to yourself at home.
According to the Mayo Clinic, the most widely prescribed osteoporosis medications for both men and women are bisphosphonates.
- Pills such as alendronate (Fosamax), ibandronate (Boniva) or risedronate (Actonel, Atelvia) that are taken daily, weekly or monthly
- Injections of ibandronate (Boniva) that are given once every three months
- Intravenous infusions of zoledronic acid (Reclast) that are given once a year
Medicare Part D plans and Medicare Advantage plans with prescription drug coverage will cover a portion of the cost of most bisphosphonates.
How much you pay out-of-pocket for your prescription depends on your plan’s formulary, or the list of drugs covered by your plan either in part or in full. Brand-name drugs and specialty drugs will cost more than generic drugs.
The amount you pay for injectable drugs or intravenous infusions given by a health care professional in a medical office or hospital setting is different than what you might pay for a prescription you pick up at the pharmacy.
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).
You will owe a 20 percent coinsurance payment for the Medicare-approved cost of injectable drugs, and the Part B deductible applies.
- You’re a woman.
- You’re eligible for Medicare Part B and meet the criteria for 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 give yourself these injections and that your family members or caregivers are unable and unwilling to give you these injections.
You will owe nothing for the home health nurse who visits to inject the drug if you meet the above conditions.
Getting Help Paying for Your Medications
If you have Medicare and limited income and resources, the Social Security Administration may be able to help you cover the cost of your Medicare prescription drug plan through their Extra Help program.
To see if you qualify, call the Social Security Administration at 1-800-772-1213 or visit the Social Security Administration’s website to learn more and fill out an application.
What Is Osteoporosis?
Osteoporosis is a disease that causes bones to become weak and brittle.
As bones weaken and become less dense, they are more likely to fracture.
Osteoporosis-related fractures most often occur in the hip, wrist or spine.
Generally, there are few if any symptoms of osteoporosis at first.
- Back pain, caused by a fractured or collapsed vertebra
- Loss of height over time
- Poor posture
- Bones that break much more easily than expected
Several factors — including your gender, age, race, lifestyle choices and medical conditions — can increase your likelihood of developing osteoporosis.
For example, women are much more likely than men to develop osteoporosis, especially after menopause.
There is no cure for osteoporosis. Treatment is often based on how likely you are to break a bone in the next 10 years. Your risk factor is determined using such information as the results of a bone density test.
If you aren’t at high risk of a bone fracture, you may not need medication. Instead, your treatment may focus on reducing risk factors through lifestyle changes.
11 Cited Research Articles
- United Healthcare. (2021, February 10). Bone (Mineral) Density Studies (NCD 150.3). Retrieved from https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/b/bone-mineral-density-studies.pdf
- National Osteoporosis Foundation. (2019, December 17). Treatment for Osteoporosis. Retrieved from https://www.nof.org/patients/treatment/
- O’Brian, J. (2019, September 11). Osteoporosis, Bone Fractures Cost Medicare $6.3B. Retrieved from https://www.healthleadersmedia.com/finance/osteoporosis-bone-fractures-cost-medicare-63b
- Mayo Clinic. (2019, June 19). Osteoporosis: Diagnosis and Treatment. Retrieved from https://www.mayoclinic.org/diseases-conditions/osteoporosis/diagnosis-treatment/drc-20351974
- Mayo Clinic. (2019, June 19). Osteoporosis: Symptoms and Causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968
- Harvard Medical School. (2014, June). Osteoporosis Drugs: Which One is Right For You? Retrieved from https://www.health.harvard.edu/womens-health/osteoporosis-drugs-which-one-is-right-for-you
- National Osteoporosis Foundation. (2012, February). Patient Tools: What You Need to Know About Paying for Your Osteoporosis Medications. Retrieved from https://cdn.nof.org/wp-content/uploads/2016/02/patient_tools_what_you_need_to_know_about_paying_for_your_osteo_meds.pdf
- National Osteoporosis Foundation. (n.d.). What is Osteoporosis and What Causes It? Retrieved from https://www.nof.org/patients/what-is-osteoporosis
- Medicare.gov. (n.d.). Bone Mass Measurements. Retrieved from https://www.medicare.gov/coverage/bone-mass-measurements
- Medicare.gov. (n.d.). Osteoporosis Drugs. Retrieved from https://www.medicare.gov/coverage/osteoporosis-drugs
- U.S. Centers for Medicare & Medicaid Services. (n.d.). National Coverage Determination (NCD) for Bone (Mineral) Density Studies (150.3). Retrieved from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=256&ncdver=1&bc=AAAAgAAAAQAA