Prolia request form program 2026

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The document is a Check Request Form for the Prolia® Co-Pay Program, requiring patients and physicians to provide necessary information for reimbursement. It includes sections for patient enrollment confirmation, physician details, check recipient selection, and required documentation submission instructions.

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Click ‘Get Form’ to open the Prolia Request Form in the editor.
Begin by filling out the 'Patient Enrollment Confirmation' section. Enter the patient's first and last name, Prolia Co-Pay Member ID, and mailing address including city, state, and zip code.
Next, move to the 'Physician and Practice Confirmation' section. Input the physician's first and last name, practice name, and mailing address details.
In the 'Check Information' section, select whether the check recipient is the patient or practice. Ensure you provide accurate addresses for both options.
Fill in the date(s) of service in mm/dd/yyyy format and specify the amount requested. Don’t forget to sign where indicated.
If applicable, enter a preferred fax-back number for notification. Finally, submit your completed form along with any required documentation via fax or mail as instructed.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is there anything better than Prolia for osteoporosis?

is often the preferred treatment for osteoporosis, but some may benefit from or Prolia. In general, bisphosphonates (like and ) are first-choice medications for osteoporosis in men and postmenopausal women.

What does the Mayo Clinic say about Prolia?

Prolia may increase your risk of developing infections. Avoid being near people who are sick or have infections while you are receiving this medicine.

What are the documentation requirements for Prolia injection?

Documentation Requirements: Patients age and sex. Documentation supporting the diagnosis of osteoporosis. Previous treatment of osteoporosis, agents used, outcomes and adverse reactions if any. History of previous fractures, including type of fracture, cause and time since occurrence.

Is Jubbonti cheaper than Prolia?

Jubbonti is a biosimilar of Prolia. Both medications are known by the same generic name: . Biosimilars are often cheaper than the original medication.

What is the safest osteoporosis drug?

Teriparatide () and abaloparatide (Tymlos) Teriparatide and abaloparatide are safe and generally well-tolerated medications. Possible short-term side effects include nausea, dizziness, and headache.

prolia injection cost

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What is the new drug to replace Prolia?

Effective Sept. 1, 2025, Jubbonti and Wyost now replace Prolia and Xgeva, respectively, as interchangeable biosimilar products for UnitedHealthcare Medicare Advantage plans, Medicare Prescription Drug Plan and most employer group Medicare Advantage plans.

Is there a patient assistance program for Prolia?

The Amgen SupportPlus Co-Pay Program can help eligible commercially insured patients lower their out-of-pocket prescription costs, including deductible, co-insurance, and co-payment. *Eligibility criteria and program maximums apply. See .amgensupportplus.com/copay for full Terms and Conditions.

Can Prolia cause diarrhea?

Prolia side effects may be quite manageable. There are many options to minimize of prevent the side effects of Prolia. These are less common side effects (occurring in 10-29%) for patients receiving Prolia: Diarrhea Shortness of breath Low levels of calcium in your blood (hypocalcemia).