Denosumab (Prolia®)

Denosumab (Prolia) is covered for FDA‑approved non‑oncology osteoporosis indications — treatment of postmenopausal women and men at high fracture risk and glucocorticoid‑induced osteoporosis (prednisone ≥7.5 mg/day expected ≥6 months) — and oncology uses are excluded. Coverage requires documentation of diagnosis and BMD/T‑scores or fragility fracture, prior 12‑month oral bisphosphonate failure or documented intolerance/exception (or prior IV bisphosphonate, inability to take oral agents, or severe renal impairment/CKD), documentation of glucocorticoid dose/duration when applicable, dosing of 60 mg SC every 6 months, 12‑month approvals, and reauthorization with evidence of clinical benefit (stability, fewer vertebral fractures, or increased BMD).

"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..."