Medicare AdvantagePrior AuthMedium impact
Evenity® (romosozumab-aqqg) (Revised)
Humana·SC · Endocrinology, Rheumatology, Geriatrics·Medicaid
Effective date
Jan 1, 2023
We identified it
Jul 22, 2026
Summary
This is a revised Humana prior authorization policy for Evenity (romosozumab-aqqg) for treatment of osteoporosis in postmenopausal women. Key updates include clarified step therapy requirements that differ by plan type: Medicare Part D requires failure/intolerance of TWO specific therapies, Medicare Part B waives step therapy for VERY HIGH RISK patients or continuation therapy within 365 days, and Medicaid requests have NO step therapy requirements. The policy maintains a black box warning exclusion for myocardial infarction or stroke within the preceding year and limits coverage to maximum 12 monthly doses.
Action Required
By August 5, 2026 (implementation of July 22, 2026 revision): Billing and prior authorization teams must update internal policies and authorization workflows to reflect differentiated step therapy requirements by plan type. For Medicare Part D claims, require documentation of failure, contraindication, or intolerance to at least TWO of the following: Forteo (teriparatide), denosumab products (Prolia, Enoby), or Tymlos (abaloparatide). For Medicare Part B claims, waive step therapy requirements if member is VERY HIGH RISK per criteria or if requesting continuation of prior therapy within past 365 days. For Medicaid claims, remove all step therapy requirements from authorization logic. Ensure all prior authorization templates and decision trees reflect these distinctions. Update clinical staff on the 12-month dose maximum limit and cardiovascular exclusion criteria (MI or stroke within preceding year). Flag any existing authorizations that may need review if they were issued under prior step therapy rules that now differ.