Ibandronate Injection (Boniva®) Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

• All FDA approved indications not otherwise excluded from Part D
  • (FDA label indication): For the treatment of osteoporosis in postmenopausal women

Exclusion Criteria

None

Required Medical Information

None

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

Six (6) months

Other Criteria

Part D vs. Part B evaluation also applies