Prolia prior authorization required

Prior authorization required for Prolia (60 mg) — submit documentation that the patient is ≥18 years old, has one of the listed qualifying diagnoses, baseline labs/measurements meeting T‑score or FRAX thresholds, and prior inadequate response or intolerance to at least two traditional osteoporosis therapies (one must be a bisphosphonate).

• Age ≥18 years.
• One of the specified diagnoses (e.g., postmenopausal osteoporosis, glucocorticoid‑induced osteoporosis, decreasing bone mass in men, etc.).
• Baseline objective measure: (a) T‑score between -1.0 and -2.5 at specified sites plus qualifying risk factor, OR (b) FRAX 10‑year major osteoporotic fracture ≥20% or hip ≥3%, OR (c) T‑score ≤ -2.5.
• Inadequate response to or intolerance of ≥2 traditional osteoporosis treatments (oral or IV), including at least one bisphosphonate.

Xgeva prior authorization required

Prior authorization required for Xgeva — submit documentation of the specific indication and supporting clinical details depending on indication: unresectable giant cell tumor of bone in skeletally mature patients; prevention of skeletal‑related events in adults with bone metastases/multiple myeloma; or hypercalcemia of malignancy with albumin‑corrected calcium >12.5 mg/dL and prior bisphosphonate failure/intolerance as applicable.

• For giant cell tumor of bone: patient ≥12 years, diagnosis of GCTB, documented skeletal maturity, and tumor unresectable or surgery likely to cause severe morbidity.
• For prevention of skeletal‑related events: patient ≥18 years with bone metastases or multiple myeloma.
• For hypercalcemia of malignancy: patient ≥18 years with albumin‑corrected calcium >12.5 mg/dL and inadequate response or intolerance to ≥1 bisphosphonate.

Step therapy (Prolia; Xgeva hypercalcemia)

Step therapy required prior to Prolia: provider must document inadequate response to or intolerance of at least two traditional osteoporosis therapies, with at least one being a bisphosphonate.

• Traditional therapies include oral or IV treatments such as alendronate, calcitonin, ibandronate, raloxifene, risedronate, or zoledronic acid.
• For Xgeva used for hypercalcemia of malignancy, document inadequate response to or intolerance of at least one bisphosphonate.

Required documentation for Prolia (baseline labs/measure)

Submit chart notes with baseline objective measures for Prolia requests: either a qualifying T‑score at specified sites with associated risk factor, a FRAX 10‑year probability meeting threshold, or a T‑score ≤ -2.5.

• Acceptable baseline documentation: (a) T‑score between -1.0 and -2.5 at lumbar spine, total hip, femoral neck, or 33% radius plus being on aromatase inhibitor OR androgen deprivation therapy OR history of osteoporotic fracture; (b) FRAX major osteoporotic fracture ≥20% or hip ≥3%; or (c) T‑score ≤ -2.5.

Required documentation for Xgeva

For Xgeva requests, submit documentation of the diagnosis and skeletal maturity when for giant cell tumor of bone, and laboratory evidence when for hypercalcemia of malignancy (albumin‑corrected calcium >12.5 mg/dL); also document prior bisphosphonate failure/intolerance when applicable.

• Giant cell tumor of bone: documentation that patient is ≥12 years and skeletally mature and that tumor is unresectable or surgery would cause severe morbidity.
• Hypercalcemia of malignancy: albumin‑corrected calcium >12.5 mg/dL and prior inadequate response or intolerance to ≥1 bisphosphonate.

Denial triggers and risks

Denial will be issued if approval criteria are not met, if the patient will be taking another RANK ligand inhibitor concurrently, or if pre‑existing hypocalcemia has not been corrected with adequate calcium and vitamin D supplementation.

• Use when approval criteria are not met results in denial.
• Concurrent use with another RANK ligand inhibitor is a denial trigger.
• Uncorrected pre‑existing hypocalcemia despite supplementation is a denial trigger.