CommercialPrior AuthHigh impact
Denosumab (CPB 0804, reviewed 2026-06-08)
Aetna·Oncology, Rheumatology, Endocrinology +2 more·Medical Policy
Effective date
Jun 8, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its denosumab (Prolia and Xgeva) medical policy effective June 8, 2026, consolidating coverage criteria for multiple biosimilar formulations. The policy clarifies precertification requirements, specific medical necessity criteria for various indications (osteoporosis, cancer-related bone loss, hypercalcemia of malignancy), and continuation of therapy rules. All denosumab products now require precertification before approval.
Action Required
IMMEDIATE - Before June 8, 2026: (1) Billing team must update all denosumab claim submission workflows to REQUIRE precertification for Aetna commercial plans. (2) Implement precertification routing: call (866) 752-7021 or fax (888) 267-3277 for all denosumab and biosimilar requests. (3) Update encounter templates and provider order entry systems to include the expanded list of covered biosimilars (Jubbonti, Stoboclo, Conexxence, Osvyrti, Ospomyv, Bosaya, Boncresa, Bildyos, Enoby for Prolia line; Wyost, Osenvelt, Bomyntra, Jubereq, Xbryk, Aukelso, Oziltus, Bilprevda, Xtrenbo for Xgeva line). (4) Providers must verify medical necessity documentation meets specific criteria before submission: for Prolia—history of fragility fracture, T-score ≤-2.5, or osteopenia with high FRAX probability plus risk indicators; for Xgeva—multiple myeloma, bone metastases, giant cell tumor, refractory hypercalcemia of malignancy, or systemic mastocytosis (second-line). (5) For continuation therapy, ensure records document either <24 months with no adverse events OR ≥24 months with clinical benefit and no adverse effects. Failure to obtain precertification will result in claim denials.