Medicare AdvantagePrior AuthMedium impact
Evenity® (romosozumab-aqqg) (Revised)
Humana·SC · Endocrinology, Rheumatology, Geriatrics +1 more·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana revised its Evenity (romosozumab-aqqg) prior authorization policy effective January 1, 2023, with updates as of February 25, 2026. The policy applies to Medicaid and Medicare (South Carolina) and requires prior authorization for osteoporosis treatment in postmenopausal women at high or very high fracture risk. Critical change: The policy now limits Evenity to a maximum of 12 monthly doses and excludes patients with myocardial infarction or stroke within the preceding year due to black box cardiovascular warnings.
Action Required
REQUIREMENTS: By March 15, 2026 (before continued use): Billing team must update authorization management system to enforce the 12-month dose limit for Evenity claims. Prior authorization team must verify all new Evenity requests include documentation of: (1) postmenopausal status, (2) osteoporosis diagnosis, (3) high or very high fracture risk per policy criteria, and (4) no myocardial infarction or stroke within the past 12 months. For Medicare Part D requests, verify step therapy failure/intolerance documentation for at least TWO agents (Forteo, Prolia, or Tymlos). For Medicare Part B requests, verify prior zoledronic acid or denosumab treatment OR very high fracture risk status. Providers submitting claims must include cardiovascular screening in prior authorization submissions. Claims exceeding 12 doses in a plan year or from patients with recent MI/stroke will be denied. Update denial templates and communication to cite the 12-dose limit and cardiovascular exclusion criteria.