MedicaidPrior AuthMedium impact
Evenity ® (Romosozumab-Aqqg)
UnitedHealthcare·NJ · Endocrinology, Rheumatology, Geriatrics +1 more·Medical Benefit Drug Policy
Effective date
Nov 1, 2026
We identified it
Oct 3, 2026
Summary
UnitedHealthcare Community Plan of New Jersey expanded Evenity® (Romosozumab-Aqqg) coverage criteria effective November 1, 2026 to include patients with very high fracture risk (recent fractures, fractures on therapy, multiple fractures, BMD T-score <-3.0, fall risk, or elevated FRAX scores ≥30% major fracture/≥4.5% hip fracture). Coverage remains limited to 12 months maximum with specific exclusions for combination therapies and requires documentation of medical necessity.
Action Required
By November 1, 2026: (1) Billing team must update prior authorization requirements in the billing system to reflect expanded coverage criteria for Evenity® (HCPCS J7171). (2) Create/update clinical documentation checklist for providers to capture required elements: osteoporosis diagnosis, BMD T-scores with specific site measurements, fracture history (type, timing, cause), FRAX scores if applicable, prior bisphosphonate therapy history/failures/intolerances, and confirmation of no concurrent parathyroid hormone analogs or RANK ligand inhibitors. (3) Update prior auth submission forms and guidelines to specify that claims must include evidence of at least one very high fracture risk criterion AND one bisphosphonate history criterion (unless very high fracture risk criteria alone are met). (4) Configure billing system to flag and reject any Evenity® authorization requests exceeding 12 months or containing concurrent prohibited medications (Forteo, Tymlos, Prolia, Xgeva). (5) Train front-desk and clinical staff on new coverage pathway. Failure to obtain proper prior authorization with complete clinical documentation will result in claim denials.