Medicare AdvantagePrior AuthHigh impact
Prolia® (denosumab) and biosimilars (Revised)
Humana·SC · Endocrinology, Oncology, Rheumatology +2 more·Medicaid
Effective date
Jan 1, 2020
We identified it
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.
Action Required
Immediately: Billing 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. For Medicare Part B claims, create system exception allowing continuation without step-therapy requirement if within 365 days of prior therapy. Update prior authorization forms and provider education materials to clarify: (1) Five covered indications and their specific clinical criteria; (2) Black box warning regarding hypocalcemia risk in advanced CKD patients requiring pre-treatment evaluation; (3) Mandatory patient supplementation requirements (1000 mg calcium + 400 IU vitamin D daily); (4) Contraindications including hypersensitivity, pregnancy/lactation, prior bisphosphonate-related jaw necrosis, and age <18 years; (5) Administration requirements (SC injection only, healthcare provider administration required). Educate providers and billing staff that claims for biosimilar products lacking prior Prolia/Jubbonti documentation will be denied. Verify all denials are communicated to practices with appeal instructions.