CareCost Medicare allows
$30.101
per unit · ASP+6%, Q3 2026
Original Medicare: the patient owes $364.28 for a 60 mg injection
20% of the $1,821.42 Medicare allows for the drug and its administration, after the Part B deductible. A Medigap plan can take that to $0.
Estimate for your patient ↓Enter the dose, pick the plan, and add a Medigap plan if there is one. Prolia's dose does not depend on weight.
60 mg once every 6 months is the standard dose for every indication above · type over it to price a different amount
Prolia has no second administration code -- 96415 (each additional hour) does not apply to a subcutaneous injection.
Include only when a significant, separately identifiable E/M service is performed and documented (modifier 25).
| Item | Qty | Payer allows | Patient owes |
|---|---|---|---|
| Prolia (denosumab) J0897 | 60 | $1,806.06 | $361.21 |
| Subcutaneous injection, therapeutic 96372 | 1 | $15.36 | $3.07 |
| Total | $1,821.42 | $364.28 |
Medicare's 80% payment is reduced by the 2% sequester; the patient's 20% coinsurance is not affected.
The estimate above assumes the deductible is already met. Most patients are part-way through theirs for most of the year, and that changes what they owe today.
Add your work email to open these four fields and get a good faith estimate for this patient.
Original Medicare · Prolia · 60 mg
Patient owes · deductible met
Commercial estimates use the payer’s published rate and this patient’s actual benefits.
$30.101 per mg is Part B's ASP+6% rate for Q3 2026. Once the $283 Part B deductible is met, the patient owes the remaining 20% coinsurance on the drug and its administration, with no annual out-of-pocket maximum to cap it. Full explanation: How Medicare Part B drug cost sharing works →
Medicare pays J0897 per 1 mg billing unit, not per syringe or per dose. Because Prolia's label dose is a flat 60 mg for every indication, the allowed drug amount is the same $1,806.06 every time — there is no weight-based variation to price, unlike a mg/kg-dosed infused drug.
| Drug | HCPCS | ASP+6% per unit (1 mg) | For 60 units |
|---|---|---|---|
| Prolia (reference product) | J0897 | $30.101 | $1,806.06 |
| Jubbonti (denosumab-bbdz) | Q5136 | $27.665 | $1,659.90 |
| Stoboclo (denosumab-bmwo) | Q5157 | $25.979 | $1,558.74 |
| Conexxence (denosumab-bnht) | Q5158 | $28.818 | $1,729.08 |
Enoby (denosumab-qbde, Q5167) has no ASP+6% entry in any Medicare quarter to date and is omitted from this table — there is no published rate to bill it against. Xgeva, the 120 mg oncology product that shares J0897 with Prolia, is priced separately and is not shown here.
For the reference patient — 60 mg, 60 units, drug + the 96372 administration code — Medicare allows $1,821.42, and the Part B coinsurance on that is $364.28. Plans A, B, C, D, F, G, M and N cover that coinsurance in full, so those patients owe nothing per dose once the $283 deductible is met. Plans K and L do not — and because Prolia is given only twice a year, the deductible column is what decides the bill. The dose that lands before the deductible is met costs a Plan K patient $436.85; the dose after it costs $182.15. Two unequal charges six months apart, not one recurring number. See what each Medigap plan (A–N) owes on this claim →
| Plan | Covers Part B deductible ($283) | Covers Part B coinsurance | Patient owes, deductible met | Patient owes, deductible not met |
|---|---|---|---|---|
| Plan K | No | 50% | $182.15 | $436.85 |
| Plan L | No | 75% | $91.07 | $359.92 |
Only the letters that leave this patient a balance are listed. The full A–N grid, the high-deductible variants, Plan N’s office-visit carve-out and the MACRA restriction on Plans C and F are at Medigap Plans A–N.
Commercial payers negotiate their own rate for J0897, not ASP+6% — our corpus holds published rates from 37 payers, including Aetna, UnitedHealthcare, Cigna, Anthem, Regence, Premera and Kaiser. Aetna’s median is $30.13 per mg against Medicare’s $30.101, putting a 60 mg dose at $1,807.80 before benefits. Rates move by state as well as by payer, which is why the estimator above takes one. What the patient owes then depends on their specific benefits. Full explanation: How commercial drug reimbursement works →
Medicare pays the same ASP+6% rate for the Prolia drug itself no matter where it's given. Prolia is a short in-office subcutaneous injection, not an infusion, so most claims bill under the physician fee schedule's injection code (96372) rather than a hospital-outpatient facility fee. Some commercial payers apply a site-of-care rule to denosumab — our coverage corpus shows 9 of 27 policy sets require in-office or a specific outpatient setting rather than allowing any site. Our data doesn't carry a Prolia-specific hospital-outpatient facility rate, so this estimator only prices the office/physician-fee-schedule path.
Place of service (POS) is what drives that rate split. POS 11 (office) prices the admin code at the non-facility physician fee schedule rate, which is the path this estimator prices. A site-of-care rule that sends the same claim to POS 19 (off-campus hospital outpatient), POS 22 (hospital outpatient) or POS 24 (ambulatory surgical center) moves the admin code to the facility rate instead — a different number for the same CPT code. Confirm the POS on the claim before comparing an admin-fee estimate against what a payer actually paid.
| Quarter | ASP+6% per unit (1 mg) |
|---|---|
| 2025 Q1 | $27.656 |
| 2025 Q2 | $27.809 |
| 2025 Q3 | $29.237 |
| 2025 Q4 | $29.380 |
| 2026 Q1 | $29.457 |
| 2026 Q2 | $29.507 |
| 2026 Q3 (current) | $30.101 |
The Q2 2026 rate ($29.507) applied to a 60 mg dose is $1,770.42 — a figure that still shows up on outdated pages. The current Q3 2026 rate applied to the same 60 mg dose is $1,806.06. Use the quarter that is actually in effect for the claim's date of service.
On a commercial plan, the Prolia Copay Card can take the drug copay down to $0 per dose, up to $4,500 a year — on the 60 mg example above, that is the difference between the coinsurance the estimator shows and nothing at all. It does not touch the administration line, and it excludes Medicare, Medicaid and other federal program patients.
There is no free-drug route from the manufacturer: the Amgen Safety Net Foundation’s eligibility page lists 16 Amgen products and Prolia is not among them (checked September 12, 2026). On Medicare, no manufacturer program touches the coinsurance either — a diagnosis-matched foundation fund is the only path, when one is open. See every program for this patient, with current status →
$30.101 per mg for Q3 2026 (ASP+6%). The standard 60 mg dose is 60 units, so Medicare's allowed drug amount is $1,806.06.
With the 96372 administration code, Medicare allows $1,821.42 and the patient's 20% coinsurance is $364.28 after the Part B deductible is met. A Medigap plan that covers the coinsurance in full can take that to $0.
Yes — Plans A and B cover 100% of the Part B coinsurance on a Prolia claim, the same as most standardized Medigap plans. Full explanation: what every plan letter A–N covers →
The Prolia Copay Card covers commercially-insured patients down to $0 per dose, up to $4,500 a year — it excludes Medicare, Medicaid and other federal program patients. Amgen’s Safety Net Foundation does not cover Prolia at all, so an uninsured patient has no manufacturer route. Neither path reaches a Medicare patient’s coinsurance.
Aetna's median published rate for J0897 is $30.13 per mg, negotiated rather than tied to ASP+6%, and essentially the same as Medicare's $30.101. Full explanation: how contracted rates are set and why they vary by payer and state →
Select the payer and the state in the estimator above. It reads that payer’s own published price file for J0897 and returns the median allowed amount for that state, with the sample size it came from. Rates vary by state: Anthem’s median is $29.51 per mg in California and $30.57 in Maine. Check a payer →
No. Prolia is a subcutaneous injection billed with 96372 alone — there is no infusion, and no second administration code applies. Full explanation: why administration is billed separately →
Compare the allowed reimbursement the estimator above shows against your own acquisition and administration costs. Biosimilars price below the reference product, so the margin on J0897 turns on what you pay for the syringe. CareCost estimates the allowed reimbursement only; it does not calculate acquisition cost or margin. See the estimate above ↑
Sources: CMS ASP pricing files (Q3 2026); Medicare physician fee schedule (96372, national non-facility); Medicare Part B deductible (2026); Medicare Rights Center 2026 Medigap plan benefits chart; 37 commercial payer published price files (Q2 2026); Prolia Copay Card and Amgen Safety Net Foundation terms and status (public/programs-bundle.js, generated from the live programs corpus).
Reviewed September 11, 2026 by Erin Rose, CareCost Estimate founder. Methodology →