Prior Authorization Form for Denosumab (Prolia/Xgeva and biosimilars)
A prior authorization form used by Anthem HealthKeepers Plus Medicaid products in Virginia to request coverage for denosumab products (Prolia, Xgeva, and multiple biosimilars). The form documents member, prescriber, diagnosis, and specific clinical criteria required to approve an initial 6-month supply or a 12-month renewal.
No material clinical/coverage changes — this is an administrative PA form with no listed policy changes.
Policy summary
This administrative Prior Authorization (PA) form is used to request coverage for denosumab products (Prolia, Xgeva, and multiple denosumab biosimilars/bioequivalents) for Anthem HealthKeepers Plus Medicaid products in Virginia. The form documents member, prescriber, diagnosis, drug, and clinical criteria to determine eligibility for approved indications including osteoporosis, glucocorticoid‑induced osteoporosis, cancer‑related bone loss and prevention of skeletal events, giant cell tumor of bone, and hypercalcemia of malignancy.
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