Summary
Effective 2027-01-01, UnitedHealthcare Community Plan (Medicaid, national) revised its denosumab medical benefit drug policy: five new biosimilars were added (Boncresa, Jubereq, Osvyrti, Oziltus, Ponlimsi), Jubereq and Osvyrti are designated preferred products, Boncresa, Oziltus and Ponlimsi are non-preferred, and HCPCS Q5166, Q5171 and Q5173 were added. The osteoporosis coverage criteria were expanded to add a very-high-fracture-risk initial therapy requirement.
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What to do
Action · 3 steps
01Before 2027-01-01: Billing team should update the denosumab product list in charge entry so that Jubereq and Osvyrti are selected as the preferred products and Boncresa, Oziltus and Ponlimsi are flagged as non-preferred for Community Plan Medicaid members, and add HCPCS Q5166, Q5171 and Q5173 to the drug code table.
02Providers and front desk staff should be told that initial osteoporosis denosumab therapy for these members will require documentation that the patient meets the very-high-fracture-risk criteria (recent fracture within 12 months, fracture on approved therapy, multiple fractures, fracture on skeleton-harming drugs, BMD T-score below -3.0, high fall risk or injurious fall history, or FRAX thresholds of 30% major osteoporotic or 4.5% hip fracture), and the prior authorization packet should be updated to collect that documentation.
03Claims for non-preferred products without the criteria documented are likely to be denied, so the billing team should check prior authorization status before scheduling administration of these products.
Codes mentioned
Q5166Q5171Q5173
Original notice
Denosumab
uhcprovider.com · Always check the source before changing claims.
Related changes
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