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Prolia® (denosumab) biosimilars (New)
Act
by Jul 1, 2026
Effective date
Jul 1, 2026
Identified
Jul 2, 2026
Replaced. This version was replaced by Prolia® (denosumab) biosimilars (Revised) (effective Jul 1, 2026).
Summary
Humana has released a new prior authorization policy effective July 1, 2026 covering Prolia (denosumab) and eight biosimilars for five indications: glucocorticoid-induced osteoporosis, osteoporosis, nonmetastatic prostate cancer, hormone-receptor-positive breast cancer, and postmenopausal osteopenia. For Medicare requests, Prolia and Enoby are preferred; non-preferred biosimilars require step therapy (trying preferred products first). Step therapy does NOT apply to Medicaid requests. All patients require calcium 1000 mg and vitamin D 400 IU daily supplementation.
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What to do
by Jul 1, 2026 · 6 steps
01Billing and clinical teams must implement prior authorization requirements in the billing system for all denosumab products (Prolia, Enoby, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv, Bosaya, Osvyrti) across the five covered indications.
02Distinguish Medicare and Medicaid workflows.
03Medicare: Configure system to require step therapy for non-preferred biosimilars—claims must document that member tried or cannot use Prolia AND Enoby first; exception: continuation of therapy within past 365 days does not require step therapy.
04Medicaid: Configure system to NOT require step therapy; prior auth approval is based solely on diagnosis and clinical criteria match.
05Update encounter forms and provider templates to prompt documentation of: diagnosis (one of five indications), relevant clinical parameters (e.g., BMD T-score for osteopenia, androgen deprivation therapy status for prostate cancer, aromatase inhibitor use for breast cancer), calcium/vitamin D supplementation status, and renal function (CKD screening per black box warning).
06Train billing staff on new biosimilar product names.
If missed: Failure to obtain prior authorization before claims submission will result in denials.
Original notice
Prolia® (denosumab) biosimilars (New)
mcp.humana.com · Always check the source before changing claims.