Approved for: office administration
Indications for Prior Authorization
- Post Menopausal Osteoporosis
- Bone metastasis in breast cancer and multiple myeloma
- Osteopenia in breast cancer, secondary to hormone ablation therapy
- To increase bone mass in men with osteoporosis
- Osteopenia in prostate cancer, secondary to androgen deprivation therapy
The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.
- Padgett's disease
- prevention of Osteoporosis
- any other diagnosis not listed in the approved indications
All of the following must be met:
Post-Menopausal Osteoporosis or to Increase Bone Mass in Men with Osteoporosis
Treatment of osteoporosis in postmenopausal woman
T-score is more than -2.5 SD below the young normal or the presence or history of osteoporotic fracture
Intolerable side effects with two of the following oral bisphosphanates: Fosamax or Actonel and Boniva.
For patients with intrinsic swallowing mechanism defect who cannot take any oral medication.
Patient is not hypocalcemic.
Intolerant to zoledronic acid yearly.
Must be prescribed by a rheumatologist or endocrinologist or for patients with breast cancer, an oncologist
Osteopenia in breast cancer
Must be prescribed by an oncologist
Patient is currently taking an aromatase inhibitor, tamoxifen, or GNRH agonist
ONE of the following:
Patient is unable to take oral AND has intolerance or contraindication to an IV bisphosphonate OR
Failed on a bisphosphonate as evidenced by a documented worsening BMD on a bisphosphonate following at least one year of therapy, or had a non-traumatic fracture while on a bisphosphonate
Osteopenia in prostate cancer
Patient is currently taking androgen deprivation therapy [e.g. gonadotropin-releasing hormone GnRH agonists such as leuprolide(Lupron)] or has had surgical castration
ONE of the following:
Patient is unable to take oral bisphosphonate AND has intolerance or contraindication to an IV bisphosphonate
Failed on a bisphosphonate following at least one year of therapy, or had a non-traumatic fracture while on a bisphosphonate
The recommended dose is 60 mg every six months.
All patients should receive one gram of calcium and 400 IU of vitamin D daily.
The drug is not covered for:
combination therapy with other agents for osteoporosis
any indication not listed in this policy
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: September 2014 Reviewed: