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abaloparatide — Blue Cross Blue Shield of Texas

glucocorticoid-induced osteoporosis

Initial criteria

  • Diagnosis of osteoporosis AND all of the following:
  • - For males: age ≥ 50 years OR requested agent medically appropriate for patient’s age and sex
  • - For females: postmenopausal OR requested agent medically appropriate for sex and menopause status
  • - Diagnosis confirmed by ONE of: fragility fracture in hip or spine OR T-score ≤ -2.5 OR T-score between -1.0 and -2.5 PLUS (fragility fracture of proximal humerus, pelvis, or distal forearm OR FRAX 10-year probability major osteoporotic fracture ≥ 20% OR FRAX 10-year probability hip fracture ≥ 3%)
  • - ONE of the following fracture risk criteria:
  • • Patient at very high fracture risk defined by at least ONE of: recent fracture within past 12 months OR fractures while on osteoporosis therapy OR multiple fractures OR fractures while on skeletal-harm drugs (e.g., long-term glucocorticoids) OR very low T-score (< -3.0) OR high risk/history of injurious falls OR very high fracture probability by FRAX (major >30%, hip >4.5%) OR other validated risk algorithm
  • • OR BOTH: (1) documentation or prescriber statement of stage 4 advanced metastatic cancer with use to treat cancer or associated condition [chart notes required]; AND (2) use consistent with best practices, peer-reviewed evidence, and FDA approval
  • - OR Patient has tried and inadequate response to a bisphosphonate (records required)
  • - OR intolerance or hypersensitivity to bisphosphonate (records required)
  • - OR FDA-labeled contraindication to ALL bisphosphonates (records required)
  • Diagnosis of glucocorticoid-induced osteoporosis AND all of the following:
  • - Currently initiating or taking glucocorticoids ≥ prednisone 5 mg/day AND expected course ≥ 3 months
  • - AND ONE of the following:
  • • Patient age < 40 years AND (prior fracture OR glucocorticoids ≥ prednisone 30 mg/day OR cumulative prednisone ≥ 5 g/year)
  • • Patient age ≥ 40 years AND (prior osteoporotic fracture OR T-score ≤ -2.5 OR FRAX major ≥ 20% OR FRAX hip ≥ 3% OR glucocorticoids ≥ prednisone 30 mg/day >30 days OR cumulative prednisone ≥ 5 g/year)
  • • Tried and inadequate response to a bisphosphonate (records required)
  • • Intolerance or hypersensitivity to bisphosphonate (records required)
  • • FDA labeled contraindication to all bisphosphonates (records required)
  • If request is for brand when generic exists:
  • - ONE of the following:
  • • Intolerance or hypersensitivity to generic equivalent OR
  • • FDA labeled contraindication to generic equivalent OR
  • • Support for use of brand over generic AND patient currently stable on brand [chart notes required] OR
  • • Tried and inadequate response to generic equivalent OR
  • • Generic discontinued due to lack of efficacy, diminished effect, or AE [chart notes required] OR
  • • Intolerance, hypersensitivity, contraindication, expected ineffectiveness, significant adherence barrier, worsening comorbidity, decreased function, or adverse reaction/harm from generic [chart notes required]