Romosozumab-aqqg (Evenity) (CPB 0954, reviewed 2026-02-20)

By February 20, 2026: Billing and prior authorization teams must implement the following: (1) Require precertification for ALL Romosozumab-aqqg (Evenity) claims (CPT 96372 with HCPCS J3111) before submission; (2) Update billing system to verify patient meets approval criteria: history of fragility fractures OR T-score ≤ -2.5 OR osteopenia with high FRAX probability PLUS indicators of very high fracture risk, inadequate response to prior injectable therapy, or inadequate response to oral bisphosphonates; (3) Configure system to deny coverage for patients with myocardial infarction or stroke within preceding year; (4) Limit approval to maximum 12 monthly doses per member; (5) Deny all off-label indications (glucocorticoid-induced osteoporosis, rheumatoid arthritis, hemodialysis-related, osteogenesis imperfecta, pregnancy/lactation-associated, renal osteodystrophy, hip/tibial fractures unrelated to postmenopausal osteoporosis); (6) Update precertification forms and provider communications with phone number (866) 752-7021 and fax number (888) 267-3277; (7) Train billing staff to flag claims requiring Statement of Medical Necessity (SMN) documentation. Claims submitted without precertification or that exceed 12 doses will be denied. Providers must ensure calcium and vitamin D supplementation and hypocalcemia correction prior to therapy initiation.