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Tymlos — CareFirst (Caremark)

Postmenopausal osteoporosis at high risk for fracture

Preferred products

  • zoledronic acid (Reclast)
  • denosumab (Prolia, Jubbonti, Ospomyv, Stoboclo)
  • teriparatide (Forteo)
  • oral bisphosphonate

Initial criteria

  • Postmenopausal Osteoporosis: Authorization of an initial total of 12 months may be granted when EITHER of the following criteria is met:
  • • Member has a history of fragility fractures (e.g., low trauma fracture from force similar to a fall from standing position).
  • OR
  • • Member has a pre-treatment T-score ≤ -2.5 OR the member has osteopenia (T-score > -2.5 and < -1) with a high pre-treatment FRAX fracture probability AND meets ANY of the following:
  • • Member has indicators of very high fracture risk (e.g., advanced age, frailty, glucocorticoid use, very low T-scores [≤ -3], or increased fall risk)
  • • Member has failed prior treatment with or is intolerant to previous injectable osteoporosis therapy (e.g., zoledronic acid [Reclast], a denosumab product [Prolia, Jubbonti, Ospomyv, Stoboclo], teriparatide [Forteo])
  • • Member has had an oral bisphosphonate trial of at least 1-year duration OR there is a clinical reason to avoid treatment with an oral bisphosphonate (see Appendix A)
  • Osteoporosis in Men: Authorization of an initial total of 12 months may be granted when EITHER of the following is met:
  • • Member has a history of an osteoporotic vertebral or hip fracture
  • OR
  • • Member meets BOTH of the following:
  • • Member has a pre-treatment T-score ≤ -2.5 OR the member has osteopenia (T-score > -2.5 and < -1) with a high pre-treatment FRAX fracture probability
  • • Member has had an oral or injectable bisphosphonate trial of at least 1-year duration OR there is a clinical reason to avoid treatment with a bisphosphonate (see Appendix A)
  • The cumulative duration of parathyroid hormone analogs (teriparatide and abaloparatide) must not exceed 24 months in the member’s lifetime.

Reauthorization criteria

  • Authorization of 12 months may be granted for members currently receiving the requested medication through a previously authorized pharmacy or medical benefit who have not experienced clinically significant adverse events during therapy.

Approval duration

12 months initial and reauthorization; lifetime maximum of 24 months for PTH analogs