Subject: Prolia 2026-A SGM P2023
Policy:
I. INDICATIONS
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.
A. FDA-Approved Indications
1. Treatment of postmenopausal women with osteoporosis at high risk for fracture, defined
as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who
have failed or are intolerant to other available osteoporosis therapy.
2. Treatment to increase bone mass in men with osteoporosis at high risk for fracture,
defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or
patients who have failed or are intolerant to other available osteoporosis therapy.
3. Treatment of glucocorticoid-induced osteoporosis in men and women at high risk of
fracture who are either initiating or continuing systemic glucocorticoids in a daily dosage
equivalent to 7.5 mg or greater of prednisone and expected to remain on glucocorticoids
for at least 6 months.
4. Treatment to increase bone mass in men at high risk for fracture receiving androgen
deprivation therapy for nonmetastatic prostate cancer.
5. Treatment to increase bone mass in women at high risk for fracture receiving adjuvant
aromatase inhibitor therapy for breast cancer.
B. Compendial Uses
1. Prevention or treatment of osteoporosis during androgen deprivation therapy for prostate
cancer in patients with high fracture risk
2. Consider in postmenopausal (natural or induced) patients receiving adjuvant aromatase
inhibition therapy along with calcium and vitamin D supplementation to maintain or
improve bone mineral density and reduce risk of fractures
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 Sections III.A, III.B, and III.C.
III. CRITERIA FOR INITIAL APPROVAL
A. Postmenopausal osteoporosis
Authorization of 12 months may be granted to postmenopausal members with osteoporosis
when EITHER of the following criteria is 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:
i. 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)
ii. Member has failed prior treatment with or is intolerant to previous injectable
osteoporosis therapy (e.g., zoledronic acid [Reclast], teriparatide [Forteo, Bonsity],
abaloparatide [Tymlos])
iii. 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. Osteoporosis in men
Authorization of 12 months may be granted to male members with osteoporosis when
EITHER of the following criteria is met:
1. Member has a history of an osteoporotic vertebral or hip fracture
2. Member meets BOTH of the following criteria:
i. 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)
ii. 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 12 months may be granted to members with glucocorticoid-induced
osteoporosis when ALL of the following criteria are met:
1. Member is currently receiving or will be initiating glucocorticoid therapy at an equivalent
prednisone dose of ≥ 2.5 mg/day for ≥ 3 months.
2. 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)
3. Member meets ANY of the following criteria:
i. Member has a history of a fragility fracture
ii. Member has a pre-treatment T-score less than or equal to -2.5
iii. 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)
D. Breast cancer
Authorization of 12 months may be granted to members who are receiving adjuvant
aromatase inhibition therapy for breast cancer.
E. Prostate cancer
Authorization of 12 months may be granted to members who are receiving androgen
deprivation therapy for prostate cancer.
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 either 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. APPENDICES
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)
• 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. FRAX Fracture Risk Assessment Tool
• High FRAX fracture probability:
• 10-year major osteoporosis-related 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:
- Prolia [package insert]. Thousand Oaks, CA: Amgen Inc.; January 2023.
- The NCCN Drugs & Biologics Compendium® 2023 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed October 5, 2023.
- LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022;33(10):2049-2102.
- Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis-2020 Endocr Pract. 2020;26 (Suppl 1):1-46.
- Shoback D, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. May 2020;105(3):587-594.
- Carey JJ. What is a ‘failure’ of bisphosphonate therapy for osteoporosis? Cleve Clin J of Med. 2005;72(11):1033-1039.
- 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.
- Gralow JR, Biermann JS, Farooki A, et al. NCCN Task Force Report: Bone Health in Cancer Care. J Natl Compr Canc Netw. 2013; 11(Suppl 3):S1-50.
- FRAX® Fracture Risk Assessment Tool. © Centre for Metabolic Bone Diseases, University of Sheffield, UK. Available at: https://www.shef.ac.uk/FRAX. Accessed October 6, 2023.
- Fink HA, Gordon G, Buckley L, et al. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol. 2017;69(8):1521-1537.
- Ensrud KE, Crandall CJ. Osteoporosis. Ann Intern Med. August 2017;167(03):ITC17–ITC32.
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.
April 14, 2024
