Medicare AdvantageCoverageHigh impact
MA08.052q, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Endocrinology, Rheumatology, Geriatrics +2 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
This is a NEW Medicare Advantage policy (MA08.052q) effective July 1, 2026, governing coverage and billing for Denosumab (Prolia® and Xgeva®), related biosimilars, and Romosozumab-aqqg (Evenity®). The policy establishes updated rules for these bone health medications. However, the full policy text content was not provided in this notification, so specific coverage criteria, prior authorization requirements, or billing rule changes cannot be detailed.
Action Required
By June 15, 2026: Billing team and clinical staff must obtain and review the complete MA08.052q policy text from https://medpolicy.ibx.com/ibc/ma/Pages/Site-Activity-View.aspx?FilterField1=MPSiteActivityLogMonth&FilterValue1=07&FilterField2=MPSiteActivityLogYear&FilterValue2=2026. Identify specific HCPCS codes (likely J3111 for denosumab and similar), prior authorization requirements, medical necessity documentation needs, and any billing rule changes. Update billing software, encounter forms, and provider education materials accordingly before July 1, 2026. Notify all providers prescribing bone health medications. Claims submitted after July 1, 2026 without compliance to updated coverage rules will be denied.