MedicaidCoverageHigh impact
Evenity ® (Romosozumab-Aqqg)
UnitedHealthcare·NM · Endocrinology, Internal Medicine, Geriatrics +3 more·Medical Benefit Drug Policy
Effective date
Nov 1, 2026
We identified it
Oct 3, 2026
Summary
UnitedHealthcare Community Plan of New Mexico revised coverage criteria for Evenity® (Romosozumab-Aqqg), expanding eligibility to include patients with very high fracture risk (recent fracture in past 12 months, fracture on osteoporosis therapy, multiple fractures, fractures on skeletal-harming drugs, BMD T-score <-3.0, high fall risk, or FRAX 10-year probabilities ≥30% major osteoporotic fracture or ≥4.5% hip fracture). Coverage remains limited to 12 months with specified exclusions for combination therapy and requires prior authorization.
Action Required
By October 31, 2026: (1) Billing team must update prior authorization workflows in billing system to reflect new expanded eligibility criteria for Evenity (J7171) including very high fracture risk documentation requirements. (2) Create or update authorization request templates to capture: recent fractures within 12 months, fracture history on approved osteoporosis therapy, multiple fracture occurrences, fracture history on glucocorticoids or skeletal-harming drugs, BMD T-score results (<-3.0 threshold), fall risk assessment, and FRAX 10-year fracture probability scores (≥30% major osteoporotic fracture or ≥4.5% hip fracture). (3) Providers must document at least one very high fracture risk criterion in addition to osteoporosis diagnosis and baseline BMD or fracture history to support coverage. (4) Update encounter forms and EMR templates to include checkboxes for new very high fracture risk criteria. (5) Confirm exclusion rules are enforced: no concurrent Parathyroid Hormone analogs (Forteo, Tymlos) or RANK ligand inhibitors (Prolia, Xgeva). (6) Set authorization limit to 12 months maximum; flag any reauthorization requests as requiring clinical review demonstrating continued medical necessity beyond initial 12-month period. (7) Denial logic must be implemented for claims lacking documented very high fracture risk status. Claims submitted without meeting revised criteria will be denied.