Xgeva® (denosumab) and biosimilars (New)

By May 1, 2026: Billing team must implement prior authorization requirements in the billing system for all denosumab products (Xgeva, Wyost, Osenvelt, Bomyntra, Bilprevda, Xtrenbo) when billed to Humana Medicaid Ohio. Update claim submission workflows to require PA approval before processing claims. Modify encounter forms and provider documentation templates to capture required clinical criteria: (1) For hypercalcemia of malignancy: albumin-corrected calcium >12.5 mg/dL and prior therapy/intolerance/contraindication to IV bisphosphonates; (2) For osteolytic bone metastases: solid tumor diagnosis, documented bone metastases, and disease progression/intolerance/contraindication to bisphosphonates (except prostate cancer); (3) For multiple myeloma: diagnosis and disease progression/intolerance/contraindication to bisphosphonates; (4) For giant cell tumor of bone: diagnosis only. Train billing and clinical staff to verify exclusion criteria: deny coverage if member is on concurrent bisphosphonate therapy (zoledronic acid, pamidronate). Set system alerts to flag any concurrent bisphosphonate use. Claims submitted without prior authorization or with concurrent bisphosphonate therapy will be denied. Verify this is the current version on Humana's website before implementation as policy updates may occur.