CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization Request Form for Osteoporosis and Related Bone Medications

This prior authorization form, administered by CVS Caremark for HMSA, determines coverage for specified osteoporosis and bone-related medications (e.g., Prolia and other listed products) and applies to providers requesting coverage for these drugs for HMSA members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request Form for Osteoporosis and Related Bone Medications

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization and required documentation (diagnosis, pre-treatment DEXA T-score, FRAX scores, and evidence of prior bisphosphonate therapy or contraindication) to CVS Caremark via fax 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MultipleCovered indications

>20% / >3%FRAX thresholds

≤ -2.5DEXA T-score cutoff

1 yearRequired bisphosphonate trial

Coverage Criteria and Decision Logic

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Indication-specific approval criteria

Covered when the relevant indication-specific branching criteria on the prior authorization form are met. Follow the branch for the selected indication and the nested questions to determine approval.

Indication selection: Select one indication: Postmenopausal osteoporosis (continue to #2), Osteoporosis in a male patient (continue to #20), Glucocorticoid-induced osteoporosis (continue to #100), Breast Cancer (continue to #30), Prostate Cancer (continue to #31), Other (No Further Questions)

Forms branch to distinct criteria sets based on indication

Postmenopausal initial therapy branch: If this is NOT a continuation request: evaluate fragility fracture, DEXA T-score, FRAX scores, and prior bisphosphonate history per the form flowIf fragility fracture present → No Further Questions; DEXA T-score ≤ -2.5 → continue to FRAX; FRAX major >20% or FRAX hip >3% → No Further Questions; or documented inadequate response/intolerance to ≥1‑year oral or injectable bisphosphonate or clinical reason to avoid bisphosphonates

Follow questions #2–#15 for detailed branching

Postmenopausal lower-risk branch: If pretreatment DEXA T-score is between -1.0 and -2.5: use FRAX to stratify. If FRAX major >20% or FRAX hip >3% may proceed; if below thresholds, approval requires documentation of inadequate response/intolerance to prior injectable therapy or clinical reason to avoid bisphosphonates per the formDEXA T-score between -1.0 and -2.5; FRAX major >20% or FRAX hip >3%

Follow questions #5 and #10–#15

Postmenopausal continuation and prior authorization history: If request is for continuation and the medication was previously authorized by HMSA/CVS, form indicates No Further Questions; otherwise continue evaluation per initial-therapy branch

Questions #2–#4 govern continuation and prior auth history

Osteoporosis in men: Follow similar flow as postmenopausal pathway: continuation and prior authorization checks; inadequate response/intolerance to ≥1‑year bisphosphonate or clinical reason to avoid qualifies; presence of vertebral or hip fracture or pretreatment T‑score ≤ -2.5 qualifies; FRAX ≥20% qualifiesT‑score ≤ -2.5 OR FRAX ≥20% OR history of vertebral/hip fracture; 1‑year bisphosphonate trial

Follow questions #20–#27 for male pathway branching

Glucocorticoid-induced osteoporosis: For new therapy vs continuation follow form flow. For new therapy, documentation must support current or planned glucocorticoid therapy ≥2.5 mg prednisone equivalent per day for ≥3 months. Prior inadequate response/intolerance to ≥1‑year bisphosphonate or clinical reason to avoid may allow approval; fragility fracture or improvement on therapy is assessed for continuationGlucocorticoid dose ≥2.5 mg/day for ≥3 months; 1‑year bisphosphonate trial

Follow questions #100–#106

Breast cancer and prostate cancer–related bone loss: For patients on aromatase inhibitors (breast cancer) or androgen deprivation therapy (prostate cancer), submit supporting documentation of therapy. For breast cancer, pretreatment DEXA T‑score ≤ -2.5, or FRAX major >20% or FRAX hip >3% allow proceeding per the form; other T‑score ranges follow FRAX branchingBreast cancer: DEXA T‑score ≤ -2.5; FRAX major >20%; FRAX hip >3%

Follow questions #30–#31 and #107–#109 for cancer-related pathways

If the provider selects Other as the indication on the prior authorization form, the form explicitly directs No Further Questions and does not present additional indication‑specific branching criteria. In practice this means the form contains no subsequent objective criteria for an unspecified “Other” diagnosis and the request cannot be evaluated against the indication‑specific pathways shown for postmenopausal osteoporosis, male osteoporosis, glucocorticoid‑induced osteoporosis, breast cancer or prostate cancer (the form’s branches all begin from those listed diagnoses).

Approval decisions depend on submission of objective evidence: providers must include the patient’s pre‑treatment DEXA T‑score and documented FRAX scores when prompted by the relevant branch of the form. Requests that lack these measurements where requested — for example no DEXA T‑score when the form asks for it or missing FRAX major/hip percentages — risk denial. The form also requires documentation of prior therapy in many branches: an inadequate response or intolerance to at least a 1‑year trial of oral or injectable bisphosphonates (or a documented clinical reason to avoid bisphosphonates) is required in multiple pathways. Common reasons for denials are missing DEXA/FRAX documentation, failure to show the required bisphosphonate trial or documented contraindication, or failure to meet the stated thresholds (for example, T‑score ≤ -2.5, FRAX major > 20% or FRAX hip > 3% when those thresholds are used by the branch).

Coding Fields and Clinical Thresholds

Diagnosis code fieldICD-10

ICD-10

Field for primary diagnosis ICD-10 code (document requests provider enter code)

Requested productsmixed

Product list

Prolia; Bildyos; Conexxence; Enoby; Jubbonti; Ospomyv; Stoboclo (checkboxes for requested product)

inv-06: DEXA T-score — threshold categories (≤ -2.5, between -1.0 and -2.5, ≥ -1.0)

T-score ≤ -2.5Defines high-risk bone mass category used to qualify for approval in multiple indication pathways (if pretreatment DEXA T-score ≤ -2.5, proceed per form logic).

T-score between -1.0 and -2.5Represents low bone mass/osteopenia; form directs additional risk stratification (e.g., FRAX) before approval decisions.

T-score ≥ -1.0Considered not osteopenic/osteoporotic on DEXA for the purposes of form flow; typically results in 'No Further Questions' for some branches unless other criteria met.

inv-07: FRAX major fracture — threshold used (> 20%)

FRAX major osteoporotic fracture — threshold> 20%: Used as an approval threshold on the form (if pretreatment FRAX for any major osteoporosis-related fracture > 20%, the form indicates no further questions/qualifies).

FRAX major < 20%If FRAX major is < 20%, the form continues to additional assessment steps in certain branches (e.g., proceed to hip FRAX or assess bisphosphonate history).

Documentation requirementProviders must submit supporting documentation of the pretreatment FRAX major fracture percentage when reporting this value on the form.

inv-08: FRAX hip fracture — threshold used (> 3%)

FRAX hip fracture — threshold> 3%: Used as an approval threshold on the form (if pretreatment FRAX hip fracture probability > 3%, the form indicates no further questions/qualifies).

FRAX hip < 3%If FRAX hip is < 3%, the form continues to additional assessment steps or other criteria (e.g., evaluate bisphosphonate response).

Documentation requirementProviders must submit supporting documentation of the pretreatment FRAX hip fracture percentage when reporting this value on the form.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the medications listed. Submit prior authorization requests and all required clinical documentation to CVS Caremark via fax at 1-866-237-5512. For questions about prior authorization determinations contact CVS Caremark at 1-808-254-4414. Approvals may be subject to dosing limits per FDA labeling, accepted compendia, and evidence-based guidelines. Lack of submission or missing supporting documentation may result in denial or non-coverage.

Fax: 1-866-237-5512
Caremark phone: 1-808-254-4414
Specialty Customer Care (CaremarkConnect): 1-800-237-2767

Step Therapy

Step Therapy — Bisphosphonate Trial Expected

Step therapy requirements apply. For most indications (postmenopausal osteoporosis, osteoporosis in men, glucocorticoid‑induced osteoporosis, and certain cancer‑related bone loss), documentation must show an inadequate response or intolerable adverse event to at least a 1-year trial of an oral or injectable bisphosphonate, or a documented clinical reason to avoid bisphosphonates. Submit supporting documentation of the bisphosphonate trial, inadequate response, intolerance, or clinical contraindication.

Documented ≥1 year trial of oral or injectable bisphosphonate OR clinical reason to avoid bisphosphonate
If inadequate response or intolerance, submit clinical notes and test results
For continuation requests, note prior HMSA/CVS authorization when applicable

Documentation Required

Required Supporting Documentation

Required supporting documentation must be submitted with the prior authorization request. This includes: the specific diagnosis, pretreatment DEXA T-score, pretreatment FRAX scores (major osteoporotic fracture and hip fracture) where applicable, documentation of fragility or vertebral/hip fractures if present, and evidence of prior therapies or trials (including dates and reason for discontinuation or intolerance). For glucocorticoid‑induced osteoporosis, provide documentation of glucocorticoid dose and duration when requested. Failure to provide the requested documentation may delay review or result in denial.

Diagnosis (select appropriate indication)
Pretreatment DEXA T-score (attach report)
Pretreatment FRAX scores for major fracture and hip (attach calculations)
Documentation of prior osteoporosis therapies and duration (e.g., bisphosphonate trial ≥1 year, injectable therapies)
Documentation of fragility/vertebral/hip fractures when applicable
For glucocorticoid‑induced osteoporosis: prednisone-equivalent dose and duration

Denial Risk

Documentation and Prior Authorization Required

Documentation and prior authorization are required before coverage will be considered. Submit the completed HMSA/CVS Caremark prior authorization form and all supporting clinical records via the fax number above. An attestation signed by the prescriber that the information is accurate is required on the form. Missing forms or incomplete documentation may result in non-coverage.

Completed prior authorization form with prescriber signature and date
Attach all supporting clinical records cited in the form
Incomplete submissions may be denied or returned for more information

Clinical Definitions and Assessment Scores

inv-14: Bone mass T-score by DEXA — definition and categories referenced in criteria

Definition — Bone mass T-score by DEXAThe patient's pretreatment bone mass T-score as measured by dual-energy x-ray absorptiometry (DEXA) is reported on the form and used to stratify risk and determine next steps.

Category: T-score ≤ -2.5Classified as osteoporosis on the form; often allows progression to approval or 'No Further Questions' depending on indication.

Category: T-score between -1.0 and -2.5Classified as low bone mass/osteopenia; the form requires additional risk assessment (e.g., FRAX) or prior therapy documentation before approval decisions.

Category: T-score ≥ -1.0Not osteopenic/osteoporotic per DEXA for form flow; in some branches this results in 'No Further Questions' unless other qualifying criteria are present.

inv-15: FRAX scores — definitions for major osteoporotic fracture and hip fracture used in decision logic

Definition — FRAX scoresFRAX provides estimated 10-year probabilities for (1) any major osteoporotic fracture and (2) hip fracture; the form requires submission of pretreatment FRAX values for decision-making.

FRAX major osteoporotic fracture interpretation> 20% on the pretreatment FRAX for any major osteoporotic fracture qualifies in multiple pathways (no further questions); values < 20% trigger further assessment.

FRAX hip fracture interpretation> 3% on the pretreatment FRAX hip fracture probability qualifies in multiple pathways (no further questions); values < 3% may require other criteria to be met.

OpenPayer

Prior Authorization Request Form for Osteoporosis and Related Bone Medications

Coverage Criteria and Decision Logic

Coding Fields and Clinical Thresholds

Prior Authorization and Documentation Requirements

Background and Scope

Clinical Definitions and Assessment Scores