CurrentUnitedHealthcarePolicy N/A

Wa Bone Density Regulators Prior Auth Form

A UnitedHealthcare prior authorization request form for bone density regulator medications (including Tymlos, Forteo, Prolia) capturing member, provider, medical, prior medication trial, and clinical eligibility information required to support PA decisions.

Policy Summary

PayerUnitedHealthcare

PolicyWa Bone Density Regulators Prior Auth Form

Policy CodePolicy N/A

Change TypeInformational form (no material changes)

Effective Date

Next Review Date

Key ActionComplete and fax the entire prior authorization form (including Sections A-E) to 866-940-7328 and allow at least 24 hours for review; call 800-310-6826 with questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified on this form (has_material_change = false).

3Medications addressed (Tymlos, Forteo, Prolia)

4Key clinical criteria groups

24Form fields (approximate)

Policy summary

This UnitedHealthcare Prior Authorization Request Form for Bone Density Regulators (Tymlos, Forteo, Prolia) collects member and provider identification, clinical diagnosis and ICD-10 code, medication name/strength/directions, prior medication trial details, and specific clinical eligibility indicators (e.g., sex, postmenopausal status, T-score at the femoral neck/total hip/lumbar spine, high fracture risk, osteoporosis diagnosis, prior fractures or glucocorticoid exposure). The form includes sections to document prior therapy (Section D) with dose, dates, and reason for discontinuation and asks additional, drug-specific questions for Tymlos/Forteo (prior bisphosphonate/SERM trials, cumulative parathyroid hormone therapy duration, age/closed epiphyses) and for Prolia (ADT or AI therapy indications, prior bisphosphonate and IV zoledronic acid trial, and contraindications such as uncorrected hypocalcemia or concurrent XGEVA). Completing these fields and faxing the form to the provided number supports PA decisions by supplying required clinical data and prior-treatment history needed to determine medical necessity and continuity of benefit.

Key Metadata

Policy TitleBone Density Regulators Prior Authorization Request Form

PayerUnitedHealthcare

Policy NumberN/A

StatusCURRENT

Effective Date

Scope summaryA UnitedHealthcare prior authorization request form for bone density regulator medications (including Tymlos, Forteo, Prolia) capturing member, provider, medical, prior medication trial, and clinical eligibility information required to support PA decisions.

Required clinical criteria (form fields)

All Requests

Form collects required clinical elements for all bone density regulator medication requests

Is the patient female?
Yes/No checkbox
If female, is the patient postmenopausal?
Yes/No checkbox
List T-score (at the femoral neck, total hip, or lumbar spine)BMD T-score for osteoporosis: <= -2.5 (2.5 or more standard deviations below young normal)
Free-text numeric T-score
Is the patient at high risk for fracture?
Yes/No checkbox
Is the patient at high risk for fracture as defined by BMD that is 2.5 or more standard deviations below that of a 'young normal' adult?BMD T-score for osteoporosis: <= -2.5 (2.5 or more standard deviations below young normal)
Yes/No checkbox
Does the patient have a diagnosis of osteoporosis?
Yes/No checkbox
Does the patient have a history of previous fractures or glucocorticoid use for at least 3 months at a dose of 5 mg per day of prednisone (or equivalent)?Glucocorticoid exposure threshold: >= 3 months at >= 5 mg/day prednisone or equivalent
Yes/No checkbox

Requests for Tymlos & Forteo

Additional required elements specific to parathyroid hormone analogs (Tymlos, Forteo)

Is the patient at high risk for fracture as defined by a diagnosis of osteopenia?
Yes/No checkbox
Does the patient have history of contraindication or intolerance to at least two oral bisphosphonates and one selective estrogen receptor modulator (SERM) (e.g., raloxifene)?
If yes, complete prior medication trials section with dose, dates, and reason for discontinuation
Does the patient have history of failure to a two (2) year trial of one oral bisphosphonate or one SERM (e.g., raloxifene)?Parathyroid hormone therapy duration limit: Total combined duration > 2 years (must indicate if exceeded)
If yes, complete prior medication trials section with dose, dates, and reason for discontinuation

Requests for Prolia

Additional required elements specific to denosumab (Prolia)

Is the patient a man receiving androgen deprivation therapy (ADT) for non-metastatic prostate cancer?
Yes/No checkbox
Is the patient a woman who is receiving adjuvant aromatase inhibitor (AI) therapy for breast cancer?
Yes/No checkbox
Does the patient have history of failure, contraindication, or intolerance to at least one (1) oral bisphosphonate and IV zolendronic acid?
If yes, complete prior medication trials section with dose, dates, and reason for discontinuation
Any of the following apply
- Prescribed for the prevention of osteoporosis or for the prevention or treatment of glucocorticoid-induced osteoporosis

Requests for Continuation of Therapy

Continuation requests must document ongoing benefit

Is there documentation of positive clinical benefit?
Yes/No checkbox and space for explanation and date

Thresholds & definitions

Thresholds

BMD T-score for osteoporosis<= -2.5 (2.5 or more standard deviations below young normal)

Age requirement for Tymlos/Forteo>= 18 years with closed epiphyses

Glucocorticoid exposure threshold>= 3 months at >= 5 mg/day prednisone or equivalent

Parathyroid hormone therapy duration limitTotal combined duration > 2 years (must indicate if exceeded)

Definitions

BMDBone mineral density

SERMSelective estrogen receptor modulator (e.g., raloxifene)

Relevant code fields on form

ICD-10 (diagnosis)ICD-10

ICD-10 CODE

Free-text field on form for specific diagnosis code

Actions required of submitting provider

Prior Authorization

Submit completed PA form

Complete and fax the entire prior authorization form (including Sections A-E) to 866-940-7328; allow at least 24 hours for review; call 800-310-6826 with questions.

Documentation Required

Provide prior medication trials documentation

When required, complete Section D with medication name, strength, directions, dates of therapy, and reason for failure/discontinuation for prior bisphosphonates, SERMs, IV zoledronic acid, or parathyroid hormone therapy.

Document prior use of: bisphosphonates, SERMs (e.g., raloxifene), IV zoledronic acid, parathyroid hormone

Documentation Required

Provide clinical data for fracture risk and T-score

Record T-score at femoral neck, total hip, or lumbar spine and indicate high fracture risk and osteoporosis diagnosis where applicable.

BMD T-score threshold: <= -2.5

Documentation Required

Document ongoing benefit for continuation

For continuation requests include evidence of positive clinical benefit and date.

Document changes

Current documentLatest

Form is current; no dated revision history provided in brief.

Policy Summary

PayerUnitedHealthcare

PolicyWa Bone Density Regulators Prior Auth Form

Policy CodePolicy N/A

Change TypeInformational form (no material changes)

Effective Date

Next Review Date

Key ActionComplete and fax the entire prior authorization form (including Sections A-E) to 866-940-7328 and allow at least 24 hours for review; call 800-310-6826 with questions.

SourceLink

On This Page

Has the total combined duration of parathyroid hormone (e.g., Tymlos, Forteo) therapy exceeded 2 years?

Parathyroid hormone therapy duration limit: Total combined duration > 2 years (must indicate if exceeded)

Does the patient have an increase in bone mass with primary or hypogonadal osteoporosis at high risk for fracture?

Yes/No checkbox

Does the patient have a diagnosis of osteoporosis associated with sustained systemic glucocorticoid therapy at high risk for fracture?

Yes/No checkbox

Is the patient 18 years of age or older with closed epiphyses?Age requirement for Tymlos/Forteo: >= 18 years with closed epiphyses

Yes/No checkbox

Uncorrected pre-existing hypocalcemia

Checkbox

Currently pregnant

Checkbox

Currently receiving XGEVA (denosumab)

Checkbox