Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
alendronate 10mg, 70mg
alendronate plus cholecalciferol (vitamin D3) 70mg/5600 IU

Criteria Approval Period
Clinical or radiographically documented fracture due to osteoporosis

OR

Glucocorticoid-induced osteoporosis in patients who are receiving or expected to receive the equivalent dose of 7.5 mg of prednisone per day or greater AND for 90 consecutive days or longer.

Indefinite

 

1 year

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Clinical fracture is defined as a symptomatic (painful) fracture.
  • Radiographically-documented fracture is defined as a fracture identified by X-ray (e.g., vertebral compression fracture). This may be asymptomatic.
  • Coverage is intended for patients taking glucocorticoids with significant systemic absorption only (e.g., by oral or parenteral routes).

Online Forms (PDF 132K)
Click on the link to complete a Special Authority request form.