Breast cancer - for members who are receiving adjuvant aromatase inhibition therapy for breast cancer.
Prolia copay card program trial#
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 and Appendix B) and.Member is currently receiving or will be initiating glucocorticoid therapy at an equivalent prednisone dose of greater than or equal to 2.5 mg/day for 3 months or more and.Glucocorticoid-induced osteoporosis - when all of the following criteria are met: 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 and Appendix B).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 C) and.Member meets both of the following criteria:.Member has a history of an osteoporotic vertebral or hip fracture or.Osteoporosis in men - when any of the following criteria are met: 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).Member has failed prior treatment with or is intolerant to previous injectable osteoporosis therapy (e.g., zoledronic acid, teriparatide, abaloparatide )) or.Member has indicators of very high fracture risk (e.g., advanced age, frailty, glucocorticoid use, very low T-scores, or increased fall risk) or.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 C) and meets any of the following criteria:.Member has a history of fragility fractures or.Postmenopausal osteoporosis - when any of the following criteria are met: ProliaĪetna considers denosumab (Prolia) medically necessary for the following indications: Medicare Part B plans: Precertification of denosumab (Prolia or Xgeva) is required of participating providers and members in applicable Medicare Part B plan designs. Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background ReferencesĬommercial plans: Precertification of denosumab (Xgeva) is required of all Aetna participating providers and members in applicable plan designs.
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