Special Authority Criteria - Denosumab

Generic Name / Strength / Form
denosumab

Criteria Approval Period

For women with postmenopausal osteoporosis with clinical or radiographically-documented fracture due to osteoporosis

AND

Contraindication to oral bisphosphonates for one of the following reasons:

  • immune-mediated hypersensitivity reaction to oral bisphosphonates; OR
  • abnormalities of the esophagus which delay esophageal emptying such as stricture or achalasia.
 Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Details regarding a patient’s contraindication to oral bisphosphonates is required as part of the Special Authority request.
  • 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.

Special Authority Request Forms

General Special Authority Request. (PDF 133K)