- Bone Loss Treatments:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
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: all other conditions
Required Medical Information: History of vertebral fracture or low trauma or fragility fractures
Supporting Documentation Must Be Submitted: No
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: 1 year(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
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
- Prior Authorization: Bone Loss Treatments:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Osteoporosis: Post Menopausal Women:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
- Quantity Limit: 1 syringe per 180 day(s).
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
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