Denosumab (Prolia®)

Prolia (denosumab) is covered only for FDA‑approved non‑oncology osteoporosis indications — postmenopausal women and men at high fracture risk and glucocorticoid‑induced osteoporosis (≥7.5 mg prednisone daily and expected ≥6 months); oncology uses are excluded. Coverage requires documentation of the FDA indication plus either an osteoporotic/fragility fracture or specified BMD/T‑score criteria (≤‑2.5 or ‑1.0 to ‑2.5 with high fracture risk) and generally a 12‑month trial of oral bisphosphonate with inadequate response unless there is documented intolerance, inability to take oral therapy, prior IV bisphosphonate, severe renal impairment (CrCl <35 mL/min) or CKD; dosing is 60 mg SC every 6 months, initial approval is for 12 months, and reauthorization requires stability, reduction in vertebral fractures, or increased BMD with appropriate documentation.

"Treatment of postmenopausal women with osteoporosis at high risk for fracture (defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or a..."