Tymlos (abaloparatide) — Highmark

Initial criteria

• The member is at high risk for a fracture as defined by one of the following: (a) history of a previous hip fracture (ICD-10: M84.35) or vertebral fracture (ICD-10: S22.0); OR (b) diagnosis of osteoporosis (ICD-10: M80-M81) defined as a T-score ≤ -2.5; OR (c) diagnosis of osteopenia with T-score between -1.0 and -2.5 AND one of: (i) 10-year risk of major osteoporotic fracture ≥ 20% using FRAX; OR (ii) 10-year risk of hip fracture ≥ 3% using FRAX.
• The member has experienced therapeutic failure or intolerance to one bisphosphonate, or all bisphosphonates are contraindicated.
• The total cumulative duration of Tymlos therapy does not exceed 24 months.
• The member is not receiving Tymlos in combination with other parathyroid hormone analogs, RANKL inhibitors, or sclerostin inhibitors.

Reauthorization criteria

• Prescriber confirms ongoing high risk for fracture.
• Total cumulative duration of Tymlos therapy does not exceed 24 months.

Approval duration

up to 24 months