Medicare AdvantageCoverageMedium impact
MA08.052n, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Endocrinology, Oncology, Rheumatology +1 more·Pharmacy
Effective date
Feb 24, 2025
We identified it
Jun 19, 2026
Summary
Medicare Advantage plans updated their medical necessity criteria for denosumab (Prolia, Xgeva) and biosimilars, as well as romosozumab-aqqg (Evenity) effective February 24, 2025. This affects coverage requirements for these bone loss medications commonly used in osteoporosis and cancer-related bone disease treatment.
Action Required
Immediately: Review updated medical necessity criteria for denosumab (Prolia, Xgeva) and romosozumab-aqqg (Evenity) prescriptions for Medicare Advantage patients. Ensure providers document medical necessity according to new criteria before prescribing these medications. Update prior authorization workflows if needed to prevent claim denials.