CommercialCoverageMedium impact
08.00.94t, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Endocrinology, Rheumatology, Oncology +1 more·Pharmacy
Effective date
Feb 24, 2025
We identified it
Jun 19, 2026
Summary
Medical necessity criteria for Denosumab (Prolia®, Xgeva®), related biosimilars, and Romosozumab-aqqg (Evenity®) have been updated for commercial plans. This affects coverage requirements and approval processes for these bone-targeted medications used in osteoporosis and cancer treatment.
Action Required
By February 24, 2025: Review updated medical necessity criteria for Denosumab and Romosozumab prescriptions. Billing team must ensure providers document updated criteria requirements before submitting claims. Update prior authorization request templates to reflect new medical necessity standards for these bone therapy medications.