UnitedHealthcareMedicaid · Coverage · Medical Benefit Drug Policy · KY · Endocrinology, Rheumatology, Oncology +3 moreHigh impact
Denosumab
Effective date
Jan 1, 2027
Identified
Nov 7, 2026
Summary
UnitedHealthcare Community Plan of Kentucky's Medicaid medical policy for denosumab was revised effective 2027-01-01, updating the list of covered denosumab products by adding Boncresa, Jubereq, Osvyrti, Oziltus, and Ponlimsi, with Jubereq and Osvyrti designated preferred and Boncresa, Oziltus, and Ponlimsi designated non-preferred. Coverage for postmenopausal osteoporosis treatment was revised to add an initial-therapy criterion for very high fracture risk (a fracture in the past 12 months or a fracture while on approved osteoporosis therapy), and HCPCS codes Q5166, Q5171, and Q5173 were added. Billing staff should update product and code references and review the new very-high-risk documentation requirements before submitting denosumab claims for these members.
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01By 2027-01-01: Before submitting denosumab claims for Kentucky Medicaid members, the billing team should update the product list in charge entry to reflect preferred products (Jubereq, Osvyrti) and non-preferred products (Boncresa, Oziltus, Ponlimsi), and add HCPCS Q5166, Q5171, and Q5173 to the denosumab code set.
02Providers and front desk staff should be told that initial osteoporosis therapy now requires documentation of very high fracture risk (recent fracture in the past 12 months or fracture while on approved osteoporosis therapy, plus the other listed criteria), and that non-preferred products require meeting the preferred product criteria in the policy.
03Claims without the required documentation are expected to be denied, so charts should be checked before the claim is released, and the practice should watch for the payer's next notice for any further updates.
Codes mentioned
Q5166Q5171Q5173
Original notice
Denosumab
uhcprovider.com · Always check the source before changing claims.
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