Prior Authorization Request (Osteoporosis Medication)

Request Information

Document title: Prior Authorization Request – Osteoporosis Medication

Request type: [Initial / Renewal / Appeal]

Urgency: [Standard / Expedited]

Expedited reason: [Clinical reason supporting expedited review] (Only include if Expedited is selected.)

Date of request: [Date]

Prescribing clinician: [Clinician name, credentials, NPI, clinic address, phone, fax]

Patient: [Patient name, DOB, MRN, payer member ID]

Requested start date: [Start date]

Expected duration: [Planned duration]

Medical Necessity Synopsis

• Medication requested: [Generic + brand; formulation/strength; dose; route; frequency; site of administration; benefit type (medical vs pharmacy)]
• Primary indication: [Osteoporosis diagnosis phenotype with ICD-10 code]
• Risk severity:
  • [Highest-impact risk qualifier 1]
  • [Highest-impact risk qualifier 2]
  • [Highest-impact risk qualifier 3]
  (Use 1–3 bullets; include only the most decision-driving items such as recent fragility fracture, very low T-score, elevated FRAX probability.)
• Prior therapy summary:
  • [Agent 1] – [Failed / Intolerant / Contraindicated]: [Single most compelling reason]
  • [Agent 2] – [Failed / Intolerant / Contraindicated]: [Single most compelling reason]
  • [Agent 3] – [Failed / Intolerant / Contraindicated]: [Single most compelling reason]
  (Use 1–3 bullets; align with payer step therapy requirements.)
• Guideline rationale:
  • [Guideline-based linkage of risk category to requested agent class]
  • [Brief statement why requested agent is appropriate now]
• Safety clearance:
  • [Key safety screen 1 addressed with date/result]
  • [Key safety screen 2 addressed with date/result]
  • [Key safety screen 3 addressed with date/result]
• Attachments: [List of documents included]

(If any element cannot be provided, include a brief statement explaining why rather than leaving it blank.)

Objective Evidence

DXA scanner facility: [Facility name/location]

Technical considerations: [Positioning artifacts, degenerative changes, hardware, or other limitations; state "None noted" if not applicable]

Date	Site	BMD (g/cm²)	T-score	Change vs Prior (%)
[Date]	[Lumbar spine / Total hip / Femoral neck / 1/3 radius]	[BMD value]	[T-score]	[Change vs prior / N/A]
[Additional rows as needed]

If DXA unavailable: [Reason unavailable] – [Alternate objective evidence] (Only include if DXA not available.)

Fracture history:

• [Site] – [Date] – [Mechanism: low-trauma / fragility / unknown] – [Imaging confirmation] – [Clinical impact if applicable]
• [Additional fractures as applicable]

FRAX assessment: (Include if calculated.)

• Tool version and date: [Version/date of calculation]
• 10-year major osteoporotic fracture probability: [Percentage]
• 10-year hip fracture probability: [Percentage]
• Key inputs: [Age, sex, prior fracture, glucocorticoids, smoking, alcohol, RA, secondary osteoporosis, femoral neck BMD if used]
• Risk underestimation factors: [Factors such as multiple fractures, very low T-scores, high fall risk; state "None" if not applicable]

Prior Osteoporosis Therapy

Drug	Dose/Frequency	Dates	Adherence Evidence	Outcome	Reason Stopped
[Agent name]	[Dose/Frequency]	[Start–Stop or ongoing]	[Fill history, infusion records, self-report]	[Failed / Intolerant / Contraindicated]	[Concise justification with supporting data]
[Additional rows as needed]

(Define "Failed" with objective endpoints such as new fracture while adherent or significant BMD decline. Specify the adverse effect for "Intolerant." Name the contraindication with supporting data for "Contraindicated.")

Calcium/Vitamin D supplementation: [Elemental Ca mg/day; Vitamin D IU/day; adherence status]

Contraindications to Alternatives

(Include when step therapy applies or to justify why lower-cost alternatives are not suitable.)

• [Alternative agent/class]: [Reason inappropriate with supporting clinical data]
• [Alternative agent/class]: [Reason inappropriate with supporting clinical data]

Requested Medication Plan

Medication: [Generic + brand; formulation; strength]

Dose, route, frequency: [Dose; route; frequency]

Duration: [Planned duration; labeled maximum and cumulative lifetime exposure if applicable]

Administration setting: [Home / Clinic / Infusion center / Other] – [Administered by patient / caregiver / clinician]

Justification: [Single sentence mapping diagnosis/risk category to requested agent with key qualifying criteria]

Safety Screening

• Calcium/Vitamin D status: [Serum calcium with date; 25-OH vitamin D with date; supplementation plan]
• Renal function: [eGFR or CrCl value with date]
• Dental/ONJ risk assessment: [Dental exam status/date; invasive dental plans; ONJ counseling status]
• Pregnancy status: [Status with date] (Include if relevant.)

Agent-specific screening: (Include only the items relevant to the requested medication.)

• Romosozumab: [Confirmation of no MI or stroke within preceding year; if history present, risk-benefit assessment]
• Denosumab: [Hypocalcemia risk status; CKD stage if relevant; transition plan if therapy discontinuation anticipated]
• PTH analogs (teriparatide/abaloparatide): [Osteosarcoma risk factor screen; orthostatic precautions for initial doses]
• IV bisphosphonate: [CrCl threshold documentation; hydration and infusion time plan]

(If any safety screen is pending, state what was ordered and the plan for proceeding.)

Sequential Treatment Plan

(Include for time-limited agents or discontinuation-sensitive agents.)

[Planned follow-on antiresorptive therapy and timing after completing romosozumab, PTH analogs, or when discontinuing denosumab]

Renewal Addendum

(Include only for renewal or reauthorization requests.)

• Current agent start date: [Date]
• Most recent administration: [Date]
• Adherence confirmation: [Yes / No] – [Supporting evidence]
• Interval fractures: [Yes / No] – [Details if yes]
• Interval DXA results: [Date, sites, BMD/T-score, percent change]
• Tolerability summary: [Adverse effects or none]
• Rationale to continue/complete course: [Clinical justification]

Attachments

• DXA reports: [Attached / Requested / Unavailable (reason)]
• Fracture imaging/reports: [Attached / Requested / Unavailable (reason)]
• Relevant labs (Ca, 25-OH Vit D, creatinine/eGFR): [Attached / Requested / Unavailable (reason)]
• Medication fill history/administration records: [Attached / Requested / Unavailable (reason)]
• Prior clinical notes: [Attached / Requested / Unavailable (reason)]
• Other supporting documents: [Attached / Requested / Unavailable (reason)]

Attestation

I attest that the information provided is accurate to the best of my knowledge and that the requested osteoporosis therapy is medically necessary for the patient identified above.

Clinician signature: ____________________________ Date: ____________

Printed name/credentials: [Name, credentials]

Amendment/Addendum notation: [Label with date and author] (Include only if this document updates a prior submission.)