To maximize the limited resources available for osteoporosis care, MCOs need medication treatment criteria focusing on elderly women (> or = 65 yr) who have suffered fractures. Programs that identify high-risk individuals encourage long-term medication adherence, and track outcomes to ensure efficient resource use. Avoiding drug therapy in low-risk patients and assuring high-risk patients receive and adhere to treatment leads to appropriate spending. Expenditure on provider education, system development, and osteoporosis medications saves costs through averting fracture care costs and can reduce the likelihood of conflicts over prescription approval, enhance osteoporosis quality scores, and improve patient satisfaction with their health care providers and MCOs. The objectives of this paper are to explain the new paradigm for osteoporosis drug therapy, and to encourage managed health organizations to implement programs that can improve the quality of osteoporosis care while achieving cost savings.