Description: Ibandronate sodium injection
Unit: 1 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 3mg IV every 3 months
Calculate drug reimbursement
(ASP: $70.48, Margin: $4.23)
# Units to bill:3
Prior auth criteria for Boniva may include but is not limited to:
1. The patient must be 18 years of age or older.
2. The patient must have a diagnosis of postmenopausal osteoporosis, either primary or secondary, or osteoporosis associated with long-term use of glucocorticoids.
3. The patient's bone mineral density test must demonstrate a T-score of -2.5 or less.
4. The patient must not have any known hypersensitivity or contraindication to ibandronate or any of the components of the formulation.
5. The patient must not have a history of gastrointestinal disorders, including dysphagia, esophagitis, or gastric ulcers.
6. The patient must not have taken any other bisphosphonate within 7 days of the proposed Boniva treatment.
7. The patient must not have any other condition that could increase the risk of adverse events associated with Boniva.
Insurance prior auth guidelines:
BONIVA (GENENTECH, INC.)
IBANDRONATE SODIUM (SAGENT PHARMACEUTICALS INC)
IBANDRONATE SODIUM (AUROMEDICS PHARMA LLC)
IBANDRONATE SODIUM (APOTEX CORP.)
IBANDRONATE SODIUM (MYLAN INSTITUTIONAL LLC)