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HumanaMedicare Advantage · Prior Auth · Medicaid · SC · Endocrinology, Oncology, Rheumatology +2 moreHigh impact

Prolia® (denosumab) and biosimilars (Revised)

Act
immediately
Effective date
Jan 1, 2020
Identified
Jun 25, 2026

Summary

Humana revised its Prolia (denosumab) and biosimilars prior authorization policy effective January 1, 2020, with updates as of March 25, 2026. The policy now includes eight denosumab products (Prolia, Jubbonti, Conexxence, Stoboclo, Bildyos, Ospomyv, Enoby, Bosaya) across five indications: glucocorticoid-induced osteoporosis, osteoporosis, nonmetastatic prostate cancer, hormone-receptor-positive breast cancer, and postmenopausal osteopenia. A critical step-therapy requirement mandates that members requesting biosimilar products (all except Prolia and Jubbonti) must have prior treatment with or documented intolerance to Prolia or Jubbonti, except for Medicare Part B continuation therapy within 365 days.

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What to do

immediately · 10 steps
01Billing and prior authorization teams must implement step-therapy edits in authorization systems to ensure all requests for Conexxence, Stoboclo, Bildyos, Ospomyv, Enoby, or Bosaya include verification of prior Prolia or Jubbonti treatment or documented intolerance.
02For Medicare Part B claims, create system exception allowing continuation without step-therapy requirement if within 365 days of prior therapy.
03Update prior authorization forms and provider education materials to clarify.
04Five covered indications and their specific clinical criteria.
05Black box warning regarding hypocalcemia risk in advanced CKD patients requiring pre-treatment evaluation.
06Mandatory patient supplementation requirements (1000 mg calcium + 400 IU vitamin D daily).
07Contraindications including hypersensitivity, pregnancy/lactation, prior bisphosphonate-related jaw necrosis, and age <18 years.
08Administration requirements (SC injection only, healthcare provider administration required).
09Educate providers and billing staff that claims for biosimilar products lacking prior Prolia/Jubbonti documentation will be denied.
10Verify all denials are communicated to practices with appeal instructions.

Original notice

Prolia® (denosumab) and biosimilars (Revised)
mcp.humana.com · Always check the source before changing claims.
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Related changes

See all Humana changes →
Prolia® (denosumab) biosimilars (New)HighEffective Jul 1, 2026 · MedicaidBrowse every Humana change in the policy list

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