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Tymlos (abaloparatide) — Blue Cross Blue Shield of New Mexico

osteoporosis

Initial criteria

  • ONE of the following:
  • Patient treated with requested agent (not on samples) within past 90 days AND at risk if therapy changed OR
  • Patient has diagnosis of osteoporosis AND ALL of the following:
  • Sex-based and age or menopause criteria met (male age ≥50 years OR medically appropriate; female postmenopausal or medically appropriate) AND
  • Diagnosis confirmed by fragility fracture hip or spine OR T-score ≤ -2.5 OR T-score -1.0 to -2.5 with fragility fracture (proximal humerus, pelvis, distal forearm) OR FRAX 10-year probability major osteoporotic fracture ≥20% OR hip fracture ≥3% AND
  • ONE of the following fracture risk criteria:
  • Very high fracture risk as defined by: recent fracture ≤12 months OR fractures on therapy OR multiple fractures OR fractures on skeletal-harming drugs (long-term glucocorticoids) OR T-score < -3.0 OR high fall risk OR high FRAX probability (major ≥30%, hip ≥4.5%) OR
  • A. Prescriber statement of stage four advanced metastatic cancer with requested agent used to treat cancer OR associated condition related to stage four metastatic cancer [chart notes required] AND use consistent with best practices, evidence-based literature, FDA approved OR
  • B. Patient has tried or cannot tolerate bisphosphonate or has contraindication to all bisphosphonates [medical records required] AND
  • Patient will NOT use requested agent in combination with bisphosphonate, denosumab (Prolia, Xgeva), romosozumab-aqqg, or another parathyroid hormone analog (e.g., teriparatide) AND
  • Patient does NOT have FDA labeled contraindications AND
  • Total lifetime duration of therapy with FORTEO, Bonsity, Teriparatide, and Tymlos ≤2 years
  • Additional approval for members in Ohio with Fully Insured or HIM Shop (SG) plans when no FDA contraindication AND either another FDA labeled indication, compendia-supported indication, or two peer-reviewed journal articles support proposed use

Approval duration

12 months; up to total of 2 years lifetime (≥3 months BCBSNM/BCBSMT)