Osteoporosis Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Osteoporosis Medications

Drugs

Quantity Limits

Actonel (Risedronate Sodium) Tablets

5mg and 30mg - 30 Tablets per 30 Days                          35mg - 4 Tablets per 28 Days                                          75mg - 2 Tablets per 28 Days                                          150mg - 1 Tablets per 30 Days

Actonel with Calcium (Risedronate Sodium - Calcium Carbonate) 35mg - 500mg Tablets 

28 Tablets per 28 Days

Boniva (Ibandronate Sodium) Tablets 

2.5mg - 30 Tablets per 30 Days                                       150mg - 3 Tablets per 84 Days

Boniva (Ibandronate Sodium) 3mg/3ml IV Syringe

Kit 1 kit per 84 Days

Didronel (Etidronate Disodium) Tablets 

200mg - 75 Tablets per 30 Days                                       400mg - 150 Tablets per 30 Days                            

Forteo (Teriparatide) Sub-Q 20mcg/dose Pen Injector

 2.4 mls per 28 Days

Fosamax (Alendronate Sodium) 70mg/75ml Solution 

300 mls per 28 Days

Fosamax (Alendronate Sodium) 35mg and 70mg Tablets

4 Tablets per 28 Days

Fosamax (Alendronate Sodium) 5mg, 10mg and 40mg Tablets 

30 Tablets per 30 Days

Fosamax Plus D (Alendronate Sodium - Vitamin D3) 70mg - 2800mg and 70mg - 5600mg Tablets    

4 Tablets per 28 Days 

Miacalcin (Calcitonin, Salmon, Synthetic) 200 Units per dose Spray/Pump 

3.7 - 3.8 mls per 30 Days

Reclast (Zoledronic Acid - Mannitol - Water) 5mg/100ml IV Infusion Bottle 

100mls per 365 Days

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