[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288311-105":53,"doc-detail-288311-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","prolia-medical-benefit-only-prescriber-prior-authorization-form-5375pro-page-1-of-2","PROLIA MEDICAL BENEFIT ONLY PRESCRIBER - PRIOR AUTHORIZATION FORM - 5375PRO - Page 1 of 2","","Prior Authorization Form for Prolia medical benefit only prescriber, requiring complete patient and provider information to support coverage decisions. The form collects patient demographics, identifiers, diagnosis, and the physician’s signature, plus procedure and diagnosis-specific eligibility checks. It includes selection among Prolia and related denosumab products, and requires confirmation of initiation versus continuation of therapy, age, fracture risk, and appropriate accompanying medication restrictions. Fax submission is specified for processing requests.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/prolia-medical-benefit-only-prescriber-prior-authorization-form-5375pro-page-1-of-2/288311/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/prolia-medical-benefit-only-prescriber-prior-authorization-form-5375pro-page-1-of-2/288311.png","ImageObject",442,249,{"name":88,"@type":89},"Quinn","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be provided on this prior authorization form?","Question",{"text":108,"@type":109},"The form requires complete patient information (date, name, date of birth, sex, address, HCPCS code, ICD-10, patient ID) and complete provider information (provider name/contact, specialty, NPI, office phone/fax, office address), plus the physician signature.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which medication options are available to select?",{"text":113,"@type":109},"The form lists Prolia (denosumab) and several denosumab-branded alternatives, including Bildyos, Conexxence, Jubbonti, Ospomyv, Stoboclo, Bosaya, and Enoby.",{"name":115,"@type":106,"acceptedAnswer":116},"What conditions must be confirmed for eligibility?",{"text":117,"@type":109},"The physician must check eligibility boxes such as age 18 or older, diagnosis criteria (osteoporosis or specified cancers receiving indicated therapies), prior bisphosphonate status, correction of hypocalcemia when applicable, high fracture risk, and restrictions against using Prolia with other authorized osteoporosis medications or other RANKL inhibitors, plus a limit of no more than two Prolia doses per 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(required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Date: |  |  |  |  | Provider Name and Office Contact: |  |  |  |\n| Patient Name: |  |  |  |  | Specialty: |  | NPI: |  |\n| Date of Birth: |  | Sex:\u003Cbr>􀂅 Male 􀂅 Female |  |  | Office Phone: | Office Fax: |  |  |\n| Street Address: |  |  |  |  | Office Street Address: |  |  |  |\n| City: |  | State: | Zip: |  | City: |  | State: | Zip: |\n| HCPCS code: |  |  |  |  | ICD-10: |  |  |  |\n| Patient ID:\u003Cbr>R |  |  |  |  | Physician Signature: |  |  |  |\n| PHYSICIAN COMPLETES |  |  |  |  |  |  |  |  |\n\n**NOTE: Form must be completed in its entirety for processing, please check ALL boxes that apply.**  \nPlease choose medication:  \n\n| 􀂅 Prolia (denosumab) | 􀂅 Bildyos (denosumab-nxxp) | 􀂅 Conexxence (denosumab-bnht) |\n| --- | --- | --- |\n| 􀂅 Jubbonti (denosumab-bbdz) | 􀂅 Ospomyv (denosumab-dssb) | 􀂅 Stoboclo (denosumab-bmwo) |\n| 􀂅 Bosaya (denosumab-kyqq) | 􀂅 Enoby (denosumab-qbde) |  |\n\n􀂅 This is INITIATION of therapy (if this is a continuation of therapy proceed to PAGE 2)  \n􀂅 Patient is 18 years of age or older  \n􀂅 Patient’s diagnosis is:  \n􀂅 Osteoporosis  \n􀂅 Breast cancer in female patient receiving *aromatase-inhibitor therapy. *Aromatase-inhibitor therapy examples: anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin)  \n􀂅 Non-Metastatic Prostate cancer in male patient receiving *androgen deprivation therapy. *Androgen deprivation therapy examples: bicalutamide (Casodex), flutamide (Eulexin), nilutamide (Nilandron), leuprolide (Lupron, Eligard), and goserelin (Zoladex)  \n􀂅 Previous treatment with bisphosphonates was ineffective or not tolerated, or treatment with bisphosphonates is contraindicated.  \n􀂅 Pre-existing hypocalcemia, if present, will be corrected prior to initiation of therapy OR patient does not have hypocalcemia.  \n􀂅 Patient at high risk for bone fracture(s) .  \n􀂅 ***Patient will NOT be using Prolia along with any other prior authorized medications for osteoporosis such as Evenity, Forteo or Tymlos AND will NOT be using Prolia with other RANKL-inhibitors like Xgeva (denosumab) .***  \n􀂅 Physician agrees that the patient will receive no more than two (2) doses of Prolia per year.  \nPLEASE CONTINUE TO PAGE 2 FOR CONTINUATION OF THERAPY REQUESTS  \nFORM 5375PRO (Eff. 1-2026) v1 Page 1 of 2  \nPROLIA MEDICAL BENEFIT ONLY PRESCRIBER  \nPRIOR AUTHORIZATION FORM  \nFax completed form to: 1-844-652-8285  \n\n| Patient Information (required) |  |  |  |  | Provider Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Date: |  |  |  |  | Provider Name and Office Contact: |  |  |  |\n| Patient Name: |  |  |  |  | Specialty: |  | NPI: |  |\n| Date of Birth: |  | Sex:\u003Cbr>􀂅 Male 􀂅 Female |  |  | Office Phone: | Office Fax: |  |  |\n| Street Address: |  |  |  |  | Office Street Address: |  |  |  |\n| City: |  | State: | Zip: |  | City: |  | State: | Zip: |\n| HCPCS code: |  |  |  |  | ICD-10: |  |  |  |\n| Patient ID:\u003Cbr>R |  |  |  |  | Physician Signature: |  |  |  |\n| PHYSICIAN COMPLETES |  |  |  |  |  |  |  |  |\n\n**NOTE: Form must be completed in its entirety for processing, please check ALL boxes that apply.**  \nPlease choose medication:  \n\n| 􀂅 Prolia (denosumab) | 􀂅 Bildyos (denosumab-nxxp) | 􀂅 Conexxence (denosumab-bnht) |\n| --- | --- | --- |\n| 􀂅 Jubbonti (denosumab-bbdz) | 􀂅 Ospomyv (denosumab-dssb) | 􀂅 Stoboclo (denosumab-bmwo) |\n| 􀂅 Bosaya (denosumab-kyqq) | 􀂅 Enoby (denosumab-qbde) |  |\n\n􀂅 This is a PA renewal for CONTINUATION of therapy, the patient been on therapy with Prolia in the last 6 months, excluding samples.  \n􀂅 Patient is 18 years of age or older.  \n􀂅 Patient’s diagnosis is:  \n􀂅 Osteoporosis  \n􀂅 Breast cancer in female patient receiving *aromatase-inhibitor therapy. *Aromatase-inhibitor therapy examples: anastrozole (Arimide","cbCaibHm7vSNbvOL","https://ap.wps.com/l/cbCaibHm7vSNbvOL","pdf",389056,"English","# Patient Information\n# Provider Information\n# Medication Selection\n# Therapy Status and Eligibility Criteria\n## Initiation of Therapy\n## Continuation of Therapy (PA renewal)\n# Physician Signature and Submission","[{\"question\":\"What information must be provided on this prior authorization form?\",\"answer\":\"The form requires complete patient information (date, name, date of birth, sex, address, HCPCS code, ICD-10, patient ID) and complete provider information (provider name/contact, specialty, NPI, office phone/fax, office address), plus the physician signature.\"},{\"question\":\"Which medication options are available to select?\",\"answer\":\"The form lists Prolia (denosumab) and several denosumab-branded alternatives, including Bildyos, Conexxence, Jubbonti, Ospomyv, Stoboclo, Bosaya, and Enoby.\"},{\"question\":\"What conditions must be confirmed for eligibility?\",\"answer\":\"The physician must check eligibility boxes such as age 18 or older, diagnosis criteria (osteoporosis or specified cancers receiving indicated therapies), prior bisphosphonate status, correction of hypocalcemia when applicable, high fracture risk, and restrictions against using Prolia with other authorized osteoporosis medications or other RANKL inhibitors, plus a limit of no more than two Prolia doses per year.\"}]","PROLIA MEDICAL BENEFIT ONLY PRESCRIBER - PRIOR AUTHORIZATION FORM - 5375PRO - Page 1 of 2 | PDF",1789633354]