Medicare AdvantageCoverageMedium impact
MA08.052o, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Endocrinology, Rheumatology, Oncology +4 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Medicare Advantage has updated medical necessity criteria for Denosumab (Prolia®, Xgeva®), related biosimilars, and Romosozumab-aqqg (Evenity®). This policy change affects bone health medications commonly used to treat osteoporosis and other bone conditions, with new coverage requirements taking effect January 1, 2026.
Action Required
Before January 1, 2026: Billing team must review updated medical necessity criteria for Denosumab (Prolia®, Xgeva®) and Romosozumab-aqqg (Evenity®) at the source URL. Update prior authorization workflows and documentation requirements for Medicare Advantage patients receiving these bone health medications. Providers must ensure medical necessity documentation meets new criteria to avoid claim denials.