All PlansPrior AuthHigh impact
Denosumab Products: Denosumab (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-mobz (Boncresa);Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-desu (Osvyrti); Denosumab-adet (Ponlimsi™); Denosumab-bmwo (Stoboclo®)
BCBS Tennessee·Endocrinology, Oncology, Rheumatology +3 more·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a new medical policy covering 11 denosumab biosimilar and brand-name products for osteoporosis, cancer-related bone loss, and rheumatoid arthritis. The policy establishes coverage criteria, documentation requirements, authorization periods (12 months), and quantity limits (60mg every 6 months for most indications, every 3 months for rheumatoid arthritis). CRITICAL: Policy is approved but explicitly states 'Do Not Implement until 10/31/2026'—no billing changes should be made until that date.
Action Required
By October 30, 2026 (one day before effective date): Billing team must prepare to implement prior authorization requirements for all denosumab products (Prolia, Bildyos, Boncresa, Bosaya, Conexxence, Enoby, Jubbonti, Ospomyv, Osvyrti, Ponlimsi, Stoboclo). Update billing system to enforce 12-month authorization periods and quantity limits (60mg every 6 months for osteoporosis/cancer; 60mg every 3 months for rheumatoid arthritis). Ensure prior auth software requires documentation of: (1) indication (osteoporosis type, cancer therapy, or RA), (2) T-scores and FRAX probability if applicable, (3) prior medication failures/intolerances, and (4) for cancer patients, confirmation of active ADT or aromatase inhibitor therapy. Train providers on new documentation requirements. No implementation should occur before 10/31/2026. Claims submitted without proper authorization or documentation after this date will be denied.