All PlansPrior AuthMedium impact
Denosumab Products: (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-mobz (Boncresa);Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-desu (Osvyrti); Denosumab-bmwo (Stoboclo®)
BCBS Tennessee·Endocrinology, Rheumatology, Oncology +3 more·Medical Policy
Effective date
Jul 31, 2026
We identified it
Jun 17, 2026
Summary
New comprehensive policy for denosumab products (Prolia and 9 biosimilars) establishes specific coverage criteria, prior authorization requirements, and documentation standards for osteoporosis, cancer-related bone loss, and rheumatoid arthritis treatments. The policy includes detailed approval criteria for different patient populations and sets 12-month authorization periods with specific continuation requirements.
Action Required
Before July 31, 2026: Billing team must implement prior authorization workflows for all 10 denosumab products listed in the policy. Update systems to capture required documentation including T-scores, FRAX probability scores, fracture history, and previous treatment failures. Train staff on specific coverage criteria for postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, prostate cancer with ADT, breast cancer with aromatase inhibitors, and rheumatoid arthritis. Set up 12-month reauthorization reminders and clinical benefit tracking for continuation approvals.