Information for Physicians

Dr. David Hanley Osteoporosis Centre

Referrals

There are many treatment options available but accessing them can be confusing. This information is provided to assist physicians with up-to-date reimbursement criteria and applications for the various anti-fracture drugs. While we make every effort to keep this list up to date, changes to coverage criteria, processes and program enrollment links may occur without notice and you may need to check with the insurer/provider directly if any question.

Alendronate 70 mg once weekly, alendronate 70 mg + 5600 Units D3
Risedronate 35 mg once weekly

Regular benefit on Alberta Blue Cross

Actonel DR 35 mg once weekly
Actonel 150 mg once monthly

Not a benefit with Alberta Blue Cross

Generic brand (Zoledronic Acid)

Zoledronic Acid is administered intravenously (IV) through designated infusion programs - this service is NOT available at AHS Calgary hospitals or the Dr. David Hanley Osteoporosis Centre.

Prescribing Considerations

A typical IV Zoledronic Acid treatment course is usually three (3) annual infusions, each of which will need to be co-ordinated on a yearly basis by the prescriber. Patients should be reminded about the possibility of a post-infusion, flu-like reaction which may last a few days. Any planned, major dental surgery or implants should be completed and healed prior to starting therapy. Repeat DXA-BMD during treatment is not routinely necessary but you may consider a DXA-BMD one year after the third and final infusion, representing 'end of therapy' before embarking upon a likely several-year bisphosphonate hiatus.

Insurance coverage is through Seniors Blue Cross, non-group Blue Cross, AISH Special Authorization and private plans. Coverage for approved Special Authorization for Zoledronic acid will be automatically extended if the next prescription is filled within one year of the previous fill date. Specific infusion access instructions are listed below and are considered up-to-date as of September 2023.

Program/Service	Locations	Contact	Notes
SRx Specialty Health Clinic	Calgary	P: 403-367-1771 F: 403-286-0018	Fax prescription with patient’s contact information. SRx will contact the patient and set up the infusion appointment. The location of infusion clinic will be determined with patient according to home address and preference.
Sandstone Pharmacies - Sandstone Infusion Clinic (Glenmore Landing)	Calgary	P: 403-255-4200 Ext. 7 F: 403-236-0846	Fax prescription with patient’s contact information. Sandstone will contact the patient and set up the infusion appointment.
Bayshore Specialty Rx	Grand Prairie, Medicine Hat, Red Deer	P: 1-877-289-3997 F: 1-877-261-5196	Fax prescription with patient’s contact information. Bayshore will contact the patient and set up the infusion appointment. The location of infusion clinic will be determined with patient according to home address and preference.
Infuze™ Program	Airdrie, Barrhead, Calgary, Canmore, Fort McMurray, Lloydminister, Medicine Hat, Red Deer	P: 1-877-767-2260 F: 1-877-905-6146	Enrollment must be completed each time Zoledronic Acid is prescribed. Patient or prescriber can call Infuze to enrol. Prescription will be filled at local pharmacy.

Alberta Blue Cross Special Authorization Criteria

For the treatment of osteoporosis in patients who have a high 10-year risk (i.e., greater than 20%) of experiencing a major osteoporotic fracture, or a moderate 10-year fracture risk (10-20%) and have experienced a prior fragility fracture and at least one of the following:

For whom oral bisphosphonates are contraindicated due to an abnormality of the esophagus which delays esophageal emptying
Who have demonstrated persistent severe gastrointestinal intolerance to a course of therapy with either alendronate or risedronate
Who had an unsatisfactory response (defined as a fragility fracture despite adhering to oral alendronate or risedronate treatment fully for 1 year and evidence of a decline in BMD below pre-treatment baseline level)

Aclasta Innovator Brand

Please note that effective October 1, 2021, the For My Bones Program no longer provides any infusion services. For patients who want to purchase name-brand Aclasta, you can still arrange infusion with one of the above infusion programs for an additional fee paid by the patient.

Prescribing Considerations

Denosumab is given as a subcutaneous injection once every 6 months. The effect of the drug is rapidly lost within 1-2 months of the last dose and in some cases, if denosumab is abruptly discontinued or given later than scheduled, the patient may experience a phase of rapid bone loss and vertebral fracture. To avoid this, patients should be carefully counseled about the importance of continuing therapy with injections given at the intended 6-month intervals. In order to discontinue denosumab, most patients will require a transition to bisphosphonate therapy (usually intravenous). The DHOC physicians recommend that patients be counseled about all the above aspects of denosumab therapy prior to starting; a treatment termination or exit plan should be considered as part of the overall treatment initiation.

Alberta Blue Cross Special Authorization Criteria

For whom oral bisphosphonates are contraindicated due to drug-induced hypersensitivity (i.e., immunologically mediated)
For whom oral bisphosphonates are contraindicated due to an abnormality of the esophagus which delays esophageal emptying
For whom bisphosphonates are contraindicated due to severe renal impairment (i.e. creatinine clearance < 35 mL/min)
Who have demonstrated persistent gastrointestinal intolerance to a course of therapy with either alendronate or risedronate
Who had an unsatisfactory response (defined as a fragility fracture despite adhering to oral alendronate or risedronate treatment fully for 1 year and evidence of a decline in BMD below pre-treatment baseline level)

Note: the fracture risk can be determined by the World Health Organization's fracture risk assessment tool, FRAX.

Starting a patient on Denosumab (Prolia®) :

The Provital Support Program keeps track of the injections and provides reminder calls. Registration is optional, enrollment forms are available through the Provital program or emailing provital@patientdirect.com, the patient can also self-register by calling 1-877-776-1002.

Subcutaneous injections can be done by qualified health care providers such as community pharmacists or family physicians. Prescriptions must be written by physician for Denosumab 60mg subcutaneously every 6 months.

The typical treatment with raloxifene will be 60 mg daily; there is no medical requirement for a 'drug holiday' (unlike bisphosphonate).

Blue Cross Special Authorization Criteria

For the treatment of osteoporosis in patients with a 20% or greater 10-year fracture risk who have documented intolerance to alendronate 70 mg or risedronate 35 mg.

The typical treatment will be 20 ug subcutaneously daily x 26 months. This is usually followed by transition to a bone-preserving agent such as bisphosphonate. Recommended to offer patient enrollment in Teva-teriparatide care program to assist with access to therapy.

Not a benefit with Alberta Blue Cross - Seniors

Romosozumab (Evenity) is an anabolic therapy approved for the prevention of fractures in postmenopausal women. It is a biological therapy - human monocolonal antibody - that bind and inhibits sclerostin, a protein that normally inhibits new bone formation.

Romosozumab is given as 2 injections of 105 mg (given at the same time for a total dose of 210 mg), subcutaneously, once a month for 12 months and usually followed with anti-resorptive treatment such as bisphosphonate at the end of the 12-month therapy. Injections may be given by the pharmacist or other licensed health care provided; some patients may prefer to give their own injections and injection training is available through the patient assistance program. At present, romosozumab is not covered by Alberta's Seniors Blue Cross Program. Recommended to offer patient enrollment in Evenity patient support program to assist with access to therapy.

Not a benefit with Alberta Blue Cross - Seniors

Information for Physicians

Medication Access Instruction

Oral Bisphosphonates

Intravenous Bisphosphonates: Zoledronic Acid 5 mg for IV Infusion

Denosumab (Prolia®)

Raloxifene (Evista®)

Teriparatide (Forteo®)

Romosozumab (EVENITY®)