- Quantity Limit: limit maximum 60 EA PER 30 day(s)
- Bone Loss Treatments:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Drug Policy Based On: FDA Approved Indications
Diagnosis Types: 1 of Bone loss in men with non-metastatic Prostate Cancer receiving Anti-Androgen therapy;Bone loss in women with Breast Cancer receiving Aromatase Inhibitor therapy
Considered Investigational and Excluded from Coverage: Concomitant use with Xgeva
Required Medical Information: 2 of Chart Notes;Lab Results
Supporting Documentation Must Be Submitted: Yes
Inclusion Criteria: 1 of For breast cancer: must be receiving aromatase inhibitor therapy;For non-metastatic prostate cancer: must be receiving androgen deprivation therapy
Osteoporosis: Post Menopausal Women:
Age Requirement: >= 18
Duration: 6 Month(s)
Gender Requirement: Female
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
History of Fracture Required: Variable
BMD T-score at neck, total hip, or lumbar spine: <= -3
Self-Administration Allowed: No
Multiple fractures required: No
Documented Diagnosis: Yes
- ST_APPLIES
- Prior Authorization: PA Applies
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