abaloparatide (Tymlos™) Approval Criteria:
- A diagnosis of postmenopausal osteoporosis confirmed by the following:
- History of vertebral fracture(s) or low trauma or fragility fracture(s) [e.g., prior fracture from minor trauma such as falling from standing height or less] within the past 5 years; OR
- A Bone Mineral Density test (T-score at or below -2.5) within the last month in the spine, femoral neck, total hip, or 33% radius; OR
- Those with a T-score between -1.0 and -2.5 in the spine, femoral neck, total hip, or 33% radius, if the FRAX® 10-year probability for major osteoporotic fracture is ≥20% or the 10-year probability of hip fracture is ≥3%; AND
- One of the following [if a 12-month bisphosphonate trial is inappropriate for the member, the member must have trial of Prolia™ or a selective estrogen receptor modulator [SERM] or a patient-specific, clinically significant reason why Prolia™ or a SERM is not appropriate]:
- A minimum 12-month trial with a bisphosphonate plus adequate calcium and vitamin D; OR
- A 12-month trial of Prolia™ (denosumab), unless contraindicated, intolerant, or allergic, that did not yield adequate results; OR
- A 12-month trial of a SERM, unless contraindicated, intolerant, or allergic, that did not yield adequate results; OR
- A patient-specific, clinically significant reason why the member cannot use Forteo® (teriparatide); AND
- Treatment duration including other parathyroid hormone analogs has not exceeded a total of 24 months during the patient's lifetime; AND
- Approval will be for a maximum of 2 years of therapy; AND
- A quantity limit of one pen per 30-days will apply.
Prior Authorization form
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