Bonsity — Blue Cross Blue Shield of Montana

Initial criteria

• Patient has a diagnosis of osteoporosis and ALL of the following:
• – For male patients: age ≥ 50 years OR agent is medically appropriate for age and sex
• – For female patients: patient is postmenopausal OR agent is medically appropriate for sex and menopause status
• – Diagnosis confirmed by ONE of the following: fragility fracture in hip or spine OR T-score ≤ -2.5 OR T-score between -1.0 and -2.5 with ONE of the following: fragility fracture of proximal humerus/pelvis/distal forearm OR FRAX 10-year major osteoporotic fracture risk ≥ 20% OR FRAX 10-year hip fracture risk ≥ 3%
• – ONE of the following: patient is at very high fracture risk (recent fracture within past 12 months OR fractures while on osteoporosis therapy OR multiple fractures OR fractures while on drugs causing skeletal harm such as long-term glucocorticoids OR T-score < -3.0 OR high risk for falls or history of injurious falls OR very high fracture probability by FRAX [major >30% or hip >4.5%]) OR patient has tried and had an inadequate response to a bisphosphonate (medical records required) OR has intolerance or hypersensitivity to a bisphosphonate OR has FDA-labeled contraindication to ALL bisphosphonates OR prescriber documentation of use in stage 4 advanced, metastatic cancer consistent with best practices and FDA approval
• OR
• Patient has a diagnosis of glucocorticoid-induced osteoporosis AND ALL of the following:
• – Patient is initiating or currently taking glucocorticoids ≥ 5 mg/day prednisone equivalent, expected duration ≥ 3 months
• – ONE of the following applies:
• • Age < 40 years AND (prior fracture OR prednisone dose ≥ 30 mg/day OR cumulative prednisone dose ≥ 5 g/year)
• • Age ≥ 40 years AND (prior osteoporotic fracture OR T-score ≤ -2.5 OR FRAX 10-year major osteoporotic fracture risk ≥ 20% OR FRAX 10-year hip fracture risk ≥ 3% OR prednisone dose ≥ 30 mg/day for >30 days OR cumulative prednisone dose ≥ 5 g/year)
• – OR patient has tried and had an inadequate response to, has intolerance/hypersensitivity to, or has FDA-labeled contraindication to bisphosphonates
• If request is for a brand agent with an available generic equivalent, ONE of the following:
• – Patient has intolerance or hypersensitivity to generic equivalent not expected with brand OR FDA-labeled contraindication to generic not expected with brand OR support for use of brand over generic AND patient is currently stable on the brand OR generic was inadequate, discontinued due to lack of efficacy, or adverse event OR expected ineffective based on known patient/drug characteristics, barrier to adherence, worsen comorbidity, decrease functioning, or cause harm [chart notes required]