Limited Coverage Drugs - Special Authority Criteria
Generic Name / Strength / Form
Clinical or radiographically-documented fracture due to osteoporosis
- No practitioner exemptions
- 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.
- Intolerable side effects are defined as esophageal ulceration, erosion or stricture or lower gastrointestinal symptoms severe enough to cause discontinuation of bisphosphonates.
- Fragility fracture is defined as a fracture that occurs as a result of minimal trauma (e.g., fall from a standing height or less).
Special Authority Request Form(s)
Online Forms (PDF, 523KB)
Click on the link to complete a special authority request form.