COVERED USES:

FDA Approved Indications:

Treatment and prevention of osteoporosis in postmenopausal women.

All FDA - approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

BMD T-score

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

• Documented clinical diagnosis of osteoporosis (defined as a non-traumatic, non-pathologic spinal fracture OR spine or hip bone mineral density (BMD) T-score less than -2.5.)
OR
• Documented risk of osteoporosis (defined as BMD T-score between -2.0 and -2.5 AND one of the following risk factors: previous fracture, history of hip or spine fracture in first degree relative, body weight <127 lbs., smoking, excess alcohol intake, secondary osteoporosis (e.g. rheumatoid arthritis), and history of falls
OR
• chronic glucocorticosteroid use: >20 mg/day for > 1 month, OR 5-20 mg/day for >3 months in post menopausal women not on estrogen, OR 5-20 mg/day for >3 months AND T-score <-1.5

AND
Documented trial and "failure of" or "an intolerance to" a 12 month course of an oral bisphosphonate.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.