Osteoporosis Medications

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Osteoporosis Medications
Drugs	Quantity Limits
Actonel (Risedronate Sodium) Tablets	5mg and 30mg - 30 Tablets per 30 Days 35mg - 4 Tablets per 28 Days 75mg - 2 Tablets per 28 Days 150mg - 1 Tablets per 30 Days
Actonel with Calcium (Risedronate Sodium - Calcium Carbonate) 35mg - 500mg Tablets	28 Tablets per 28 Days
Boniva (Ibandronate Sodium) Tablets	2.5mg - 30 Tablets per 30 Days 150mg - 3 Tablets per 84 Days
Boniva (Ibandronate Sodium) 3mg/3ml IV Syringe	Kit 1 kit per 84 Days
Didronel (Etidronate Disodium) Tablets	200mg - 75 Tablets per 30 Days 400mg - 150 Tablets per 30 Days
Forteo (Teriparatide) Sub-Q 20mcg/dose Pen Injector	2.4 mls per 28 Days
Fosamax (Alendronate Sodium) 70mg/75ml Solution	300 mls per 28 Days
Fosamax (Alendronate Sodium) 35mg and 70mg Tablets	4 Tablets per 28 Days
Fosamax (Alendronate Sodium) 5mg, 10mg and 40mg Tablets	30 Tablets per 30 Days
Fosamax Plus D (Alendronate Sodium - Vitamin D3) 70mg - 2800mg and 70mg - 5600mg Tablets	4 Tablets per 28 Days
Miacalcin (Calcitonin, Salmon, Synthetic) 200 Units per dose Spray/Pump	3.7 - 3.8 mls per 30 Days
Reclast (Zoledronic Acid - Mannitol - Water) 5mg/100ml IV Infusion Bottle	100mls per 365 Days

Last Modified on Nov 12, 2020