MedicaidPrior AuthMedium impact
Prolia® (denosumab) biosimilars (New)
Humana·SC · Rheumatology, Endocrinology, Geriatrics +1 more·Medicaid
We identified it
Jul 2, 2026
Summary
This is a new Prior Authorization policy for Prolia® (denosumab) biosimilars covering Medicare and Medicaid members in South Carolina. The policy establishes requirements for prior authorization before dispensing biosimilar denosumab products. Billing teams must implement prior authorization workflows to avoid claim denials.
Action Required
Immediately: Billing team must obtain and review the complete policy details from the source URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a56a5b7) to identify specific HCPCS codes for denosumab biosimilars. Update billing system to flag all denosumab biosimilar claims for prior authorization requirement before submission. Communicate with providers and clinical staff that prior authorization is now required for Prolia® biosimilars. Train front desk and authorization staff on the specific prior authorization process. Store policy documentation for reference. Failure to obtain prior authorization will result in claim denials for affected South Carolina Medicaid and Medicare members.