Xgeva® (denosumab) and biosimiliars (Revised)

By January 1, 2026, the billing and authorization team must: (1) Update the prior authorization workflow in the billing system to require pre-approval for all denosumab products (Xgeva, Wyost, Osenvelt, Bomyntra, Bilprevda, Xtrenbo, Aukelso, Jubereq) for Medicare Advantage, Traditional Medicare Part B, and Medicaid (Kentucky and South Carolina members); (2) Configure system rules to enforce step therapy requirements: for hypercalcemia of malignancy and multiple myeloma, require documentation of prior zoledronic acid failure/intolerance/contraindication; for osteolytic bone metastases with solid tumors (excluding prostate and breast cancer), require zoledronic acid failure documentation; (3) Implement preferred product logic: flag non-preferred biosimilars (all except Xgeva and Xtrenbo) to require prior therapy failure with Xgeva/Xtrenbo before approval; (4) Add Medicare Part B continuation-of-therapy exception: bypass step therapy if claim is within 365 days of prior approval; (5) Configure exclusion rule: deny requests with concurrent bisphosphonate therapy; (6) Update claim scrubber to catch concurrent bisphosphonate codes (zoledronic acid); (7) Notify providers treating oncology patients of new prior auth requirement and preferred product hierarchy; (8) Add Giant Cell Tumor of Bone (indication code) to billing system with preferred/non-preferred logic; (9) Verify Medicaid-Kentucky and Medicaid-South Carolina are properly configured in system; (10) Claims submitted without prior authorization or failing to meet criteria will be denied.