The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
FDA-Approved Indications A. Treatment of postmenopausal women with osteoporosis at high risk for fracture (defined herein as having a history of osteoporotic fracture or multiple risk factors for fracture) or who have failed or are intolerant to other available osteoporosis therapy. B. Increase of bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy. C. Treatment of men and women with osteoporosis associated with sustained glucocorticoid therapy (daily dosage equivalent to 5 mg or greater of prednisone) at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy.
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review: Supporting chart notes or medical record indicating a history of fractures, T-score, and FRAX fracture probability as applicable to Section III.
III. CRITERIA FOR INITIAL APPROVAL
A. Postmenopausal osteoporosis Authorization of an initial total of 12 months may be granted to postmenopausal members with osteoporosis when ANY of the following criteria are met: 1. Member has a history of fragility fractures 2. Member has a pre-treatment T-score less than or equal to -2.5 OR member has osteopenia (i.e., pre-treatment T- score greater than -2.5 and less than -1) with a high pre- treatment FRAX fracture probability (See Appendix B) and meets ANY of the following criteria: a. Member has indicators of very high fracture risk (e.g., advanced age, frailty, glucocorticoid use, very low T- scores [less than or equal to -3], or increased fall risk) b. Member has failed prior treatment with or is intolerant to previous injectable osteoporosis therapy (e.g., zoledronic acid [Reclast], denosumab [Prolia], abaloparatide [Tymlos]) c. 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)
B. Primary or hypogonadal osteoporosis in men Authorization of an initial total of 12 months may be granted to male members with primary or hypogonadal osteoporosis when ANY of the following criteria are met: 1. Member has a history of an osteoporotic vertebral or hip fracture 2. Member meets BOTH of the following criteria: a. Member has a pre-treatment T-score less than or equal to -2.5 OR member has osteopenia (i.e., pre- treatment T-score greater than -2.5 and less than -1) with a high pre-treatment FRAX fracture probability (See Appendix B) b. 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)
C. Glucocorticoid-induced osteoporosis Authorization of an initial total of 12 months may be granted to members with glucocorticoid-induced osteoporosis when ALL of the following criteria are met: 1. 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) 2. Member is currently receiving or will be initiating glucocorticoid therapy at an equivalent prednisone dose of ≥ 2.5 mg/day for ≥ 3 months 3. Member meets ANY of the following criteria: a. Member has a history of a fragility fracture b. Member has a pre-treatment T-score less than or equal to -2.5 c. Member has osteopenia (i.e., pre-treatment T-score greater than -2.5 and less than -1) with a high pre- treatment FRAX fracture probability (See Appendix B)
IV. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for all members (including new members) who are currently receiving the requested medication through a previously authorized pharmacy or medical benefit, who meet one of the following: A. Member has received less than 24 months of therapy and has not experienced clinically significant adverse events during therapy B. Member has received 24 months of therapy or more and meets both of the following: 1. Member has experienced clinical benefit (i.e., improvement or stabilization in T-score since the previous bone mass measurement) 2. Member has not experienced any adverse effects
V. OTHER
The cumulative duration of parathyroid hormone analogs (e.g., teriparatide and abaloparatide) will not exceed a total of 24 months in the member’s lifetime unless the member remains at or has returned to having a high risk for fracture.
VI. APPENDIX Appendix A. Clinical reasons to avoid oral bisphosphonate therapy • Presence of anatomic or functional esophageal abnormalities that might delay transit of the tablet (e.g., achalasia, stricture, or dysmotility) • Active upper gastrointestinal problem (e.g., dysphagia, gastritis, duodenitis, erosive esophagitis, ulcers) • Presence of documented or potential gastrointestinal malabsorption (e.g., gastric bypass procedures, celiac disease, Crohn’s disease, infiltrative disorders, etc.) • Inability to stand or sit upright for at least 30 to 60 minutes • Inability to take oral bisphosphonate at least 30 to 60 minutes before first food, drink, or medication of the day • Renal insufficiency (creatinine clearance < 35 mL/min) • History of intolerance to an oral bisphosphonate
Appendix B. WHO Fracture Risk Assessment Tool • High FRAX fracture probability: 10-year major osteoporotic fracture risk ≥ 20% or hip fracture risk ≥ 3%. • 10-year probability; calculation tool available at: https://www.sheffield.ac.uk/FRAX/ • The estimated risk score generated with FRAX should be multiplied by 1.15 for major osteoporotic fracture (including fractures of the spine (clinical), hip, wrist, or humerus) and 1.2 for hip fracture if glucocorticoid treatment is greater than 7.5 mg (prednisone equivalent) per day.
Place of Service:
Outpatient
The above policy is based on the following references:
Forteo [package insert]. Indianapolis, IN: Eli Lilly and Company; September 2021.
Bonsity [package insert]. San Diego, CA: Pfenex, Inc.; October 2019.
Teriparatide [package insert]. San Diego, CA: Alvogen, Inc.; November 2019.
Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health Inc; October 24, 2019. Accessed October 10, 2022.
Cosman F, de Beur SJ, LeBoff MS, et al. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10): 2359-2381.
Jeremiah MP, Unwin BK, Greenwald MH, et al. Diagnosis and management of osteoporosis. Am Fam Physician. 2015;92(4):261-268.
Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis 2020. Endocr Pract. 2020;26 (Suppl 1):1-46.
Treatment to prevent osteoporotic fractures: an update. Department of Health and Human Services, Agency for Healthcare Research and Quality. 2012; Publication No. 12-EHC023-EF. Available at www.effectivehealthcare.ahrq.gov/lbd.cfm.
Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men : an Endocrine Society clinical practice guideline. J Clin Endocr Metab. 2012;97(6):1802-1822.
Fink HA, Gordon G, Buckley L, et al. 2017 American College of Rheumatology Guidelines for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res. 2017;69:1521-1537.
Ensrud KE, Crandall CJ. Osteoporosis. Ann Intern. Med 2017;167(03):ITC17–ITC32.
Eastell R, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2019;104:1595-1622.
Carey John. What is a ‘failure’ of bisphosphonate therapy for osteoporosis? Cleveland Clinic Journal of Medicine. Nov 2005, 72 (11) 1033-1039.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
