Limited Coverage Drugs - Zoledronic Acid

Generic Name

zoledronic acid

Strength

5 mg / 100 ml
Form intravenous solution

Special Authority Criteria

Approval Period

For women with postmenopausal osteoporosis or men with osteoporosis

AND

with a clinical or radiographically documented fracture due to osteoporosis

AND

with a contraindication to oral bisphosphonates due to abnormalities of the esophagus which delays esophageal emptying (e.g., stricture or achalasia).

Indefinite

Practitioner Exemptions

  • No practitioner exceptions.

Special Notes

  • The Special Authority Request must include details regarding a patient’s contraindication to oral bisphosphonates.
  • Clinical fracture is defined as a symptomatic (painful) fracture.
  • Radiographically-documented fracture is defined as a fracture identified by X-ray (e.g., vertebral compression fracture). This may be asymptomatic.

Special Authority Request Form(s)