CurrentMass General Brigham Health PlanPolicy N/A

Ibandronate Injection Coverage Guidelines

Defines prior authorization coverage criteria, continuation, and limitations for ibandronate sodium injection under the medical benefit for treatment or prevention of osteoporosis in postmenopausal women; includes contact info and references. Applies to Mass General Brigham Health Plan (MassHealth UPPL, Commercial/Exchange).

Policy Summary

PayerMass General Brigham Health Plan

PolicyIbandronate Injection Coverage Guidelines

Policy CodePolicy N/A

Change TypeRevised (formatting/references)operational benefit move

Effective DateJul 1, 2025

Next Review Date

Key ActionAuthorization must be obtained for ibandronate sodium injection; prescriber must submit request and resubmissions infer positive response for continuation.

SourceLink

POLICY UPDATE CHANGES

Reviewed and updated for P&T; updated formatting and references; effective 7/1/25.

7/10/24: Separated criteria from pharmacy benefit and made product available through medical benefit only; no changes to criteria.

1 yearInitial/reauthorization duration

< -3.0T-score threshold

Covered w/ criteriaCoverage stance

Coverage Summary

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Ibandronate sodium injection is covered with prior authorization under the medical benefit for the treatment and prevention of osteoporosis in postmenopausal women. This coverage applies to Mass General Brigham Health Plan populations including MassHealth UPPL and Commercial/Exchange. Authorization must be obtained per the plan's prior authorization process and is guided by the policy's clinical criteria and referenced materials (package insert and listed clinical guidelines).

Initial approvals and reauthorizations are granted for 1 year. Operational and review history notes that the product was moved to the medical benefit (effective 8/12/24) and the policy was updated as part of the annual UM review (effective 7/1/25).

Key thresholds and quick facts

Initial/reauthorization duration1 year

T-score threshold< -3.0

Covered indications/criteria countMultiple clinical risk criteria listed (e.g., recent fracture, multiple fractures, fractures on therapy, T-score < -3.0, high fall risk, FRAX very high probability, prior oral bisphosphonate intolerance/contraindication)