CurrentHawaii Medical Service Association (HMSA)Policy N/A

Evenity (romosozumab) prior authorization — postmenopausal osteoporosis

Prior authorization form and clinical criteria governing coverage of Evenity (romosozumab) for members with postmenopausal osteoporosis under CVS Caremark-administered benefit plans for HMSA members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyEvenity (romosozumab) prior authorization — postmenopausal osteoporosis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed prior authorization form and supporting documentation (DEXA, imaging, prior therapy records) to CVS Caremark Specialty Programs at 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

DEXA ≤ -3.0severe low bone density threshold

≥2 vertebralfracture history trigger

≥1 yr bisphosphonateprior therapy requirement

Prolia/Tymlosconsider prior injectables

Months askedtreatment duration capture

Coverage Criteria for Evenity (romosozumab)

Initial therapy / coverage criteria

Covered when ANY of the following branches are satisfied as laid out in the form logic:

High-risk objective findings: Member has one of: DEXA T-score ≤ -3.0; history of >2 vertebral fragility fractures; two moderate vertebral fragility fractures or vertebral body height reduction 26-40%; one severe vertebral fragility fracture or vertebral body height reduction >40%.as listed

Imaging or DEXA results must be submitted

T-score ≤ -2.5 pathway: Member has pre-treatment T-score ≤ -2.5 AND either history of vertebral or radial fracture OR documented inadequate response/intolerable adverse event to at least a 1-year trial of an oral or injectable bisphosphonate OR clinical reason to avoid bisphosphonates.T-score ≤ -2.5; ≥ 1 year bisphosphonate trial where applicable

Submit DEXA and imaging/therapy documentation as applicable

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyEvenity (romosozumab) prior authorization — postmenopausal osteoporosis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed prior authorization form and supporting documentation (DEXA, imaging, prior therapy records) to CVS Caremark Specialty Programs at 1-866-237-5512.

SourceLink

On This Page

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Requests that lack the required objective evidence or supporting documentation may be considered not medically necessary. Specifically, when DEXA T‑scores are cited a copy of the DEXA results must be submitted; imaging studies supporting any claimed vertebral or radial fractures or reductions in vertebral body height must be provided. In addition, documentation of prior therapy—such as a documented inadequate response or intolerable adverse event to at least a 1‑year trial of an oral or injectable bisphosphonate, a clinical reason to avoid bisphosphonates, or failure/intolerance to prior injectable osteoporosis therapy (e.g., Prolia, Tymlos)—must be included to support approval under the step‑therapy pathways.

Diagnosis Coding and Key Clinical Thresholds

Requested diagnosis codingICD-10

ICD-10

Documentation requests the ICD-10 code for indication (provider to supply).

Bone density and fracture thresholds — DEXA and imaging

DEXA severe thresholdDEXA T-score ≤ -3.0 (pre-treatment) — DEXA results must be submitted when cited.

DEXA standard thresholdPre-treatment bone mass T-score ≤ -2.5 (pathway requires DEXA results).

Multiple vertebral fracturesHistory of greater than 2 vertebral fragility fractures — imaging supporting fractures must be submitted.

Moderate vertebral fractures or height lossTwo moderate vertebral fragility fractures or reduction in vertebral body height of 26–40% — imaging must be submitted.

Severe vertebral fracture or height lossOne severe vertebral fragility fracture or reduction in vertebral body height >40% — imaging must be submitted.

Prior therapy duration and requirements

Required bisphosphonate trialDocumented inadequate response or intolerable adverse event to at least a 1-year trial of an oral or injectable bisphosphonate — supporting documentation must be submitted.

Bisphosphonate avoidanceClinical reason to avoid oral or injectable bisphosphonates can substitute for trial when documented.

Prior injectable therapy failureFailure of or inability to tolerate prior injectable osteoporosis therapy (e.g., Prolia, Tymlos) is considered — documentation required.

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization and Submission

Prior authorization is required through CVS Caremark Specialty Programs for medications covered under the patient’s benefit. Fax the completed HMSA/CVS Caremark prior authorization form and all supporting documentation to CVS Caremark Specialty Programs at 1-866-237-5512. For prior authorization questions contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care (eligibility, copay, delivery) contact CaremarkConnect® at 1-800-237-2767.

Send completed prior authorization form and supporting documentation to CVS Caremark Specialty Programs, Fax: 1-866-237-5512
For prior authorization inquiries: 1-808-254-4414
Specialty Customer Care (eligibility/copay/delivery): CaremarkConnect® 1-800-237-2767

Denial Risk

Insufficient Clinical Documentation — Denial Risk

Insufficient clinical documentation will result in denial or delay of the request. Common deficiencies include missing DEXA scan results when T-scores are cited, absence of imaging to confirm vertebral or radial fragility fractures, and lack of documentation of prior trials or intolerance to required therapies.

Missing DEXA scan reports when a T-score is used to justify therapy
No imaging studies (e.g., radiographs, CT, MRI) to document vertebral or radial fragility fractures
No documentation of prior trial duration or clinical details of intolerance/adverse events

Documentation Required

Required Supporting Documentation

Submit objective supporting documentation with the prior authorization request: DEXA scan results for any referenced T-scores; imaging studies (radiograph/CT/MRI) that document vertebral/radial fragility fractures or vertebral body height reduction; and clinical records detailing prior treatment trials, adverse events, or contraindications.

DEXA scan results when citing a T-score (e.g., T ≤ -2.5 or ≤ -3.0)
Imaging confirming fragility fractures or vertebral body height reduction (specify level and percent height loss)
Clinical notes documenting prior osteoporosis therapy trials, durations (e.g., ≥1 year for bisphosphonates), inadequate response, or intolerable adverse events
Documentation of clinical reasons to avoid bisphosphonates if applicable (e.g., contraindications)

Step Therapy

Required Prior Therapy

Policy requires documented prior therapy before approval in most cases. For postmenopausal osteoporosis, the member must have had a trial and inadequate response or intolerance to at least a 1-year course of oral or injectable bisphosphonates, or a documented clinical reason to avoid bisphosphonates. If applicable, documentation of failure or intolerance to prior injectable osteoporosis agents (e.g., denosumab/Prolia, abaloparatide/Tymlos) should be submitted.

Documented trial of oral or injectable bisphosphonate(s) of approximately ≥1 year with inadequate response or intolerable adverse event
Clinical justification to avoid bisphosphonates when no trial is possible
Documentation of failure or intolerance to prior injectable osteoporosis therapy when relevant (e.g., Prolia, Tymlos)

Background

This form supports coverage determination for romosozumab (Evenity) for the treatment of postmenopausal osteoporosis. It focuses on patients with severely low bone density or fragility fractures and on those who have failed or cannot tolerate bisphosphonate therapy or prior injectable osteoporosis agents. Objective evidence is required: DEXA results when T‑scores are used to meet thresholds (for example, a DEXA T‑score of ≤ -3.0 or ≤ -2.5 depending on the pathway) and imaging when vertebral or radial fractures or vertebral height reductions are claimed. The form also captures prior therapy history, including documentation of a ≥1‑year trial of an oral or injectable bisphosphonate with inadequate response or intolerance, or inability to tolerate prior injectable osteoporosis therapies, as part of the coverage criteria.

Definitions and Clinical Thresholds

DEXA T-score criteria

Primary DEXA thresholdsDocumented pre-treatment T-score thresholds referenced include ≤ -2.5 and a severe threshold of ≤ -3.0 for consideration; submit DEXA results when cited.

Evidence requirementDEXA scan copy must be submitted when a T-score pathway is used for approval.

T-score pathway linkageT-score ≤ -2.5 pathway requires additional criteria (fracture history or prior therapy failure/avoidance) to meet coverage.

Vertebral fragility fracture definitions and imaging requirements

Multiple vertebral fracturesHistory of greater than 2 vertebral fragility fractures — imaging studies supporting fractures must be submitted.

Two moderate fractures or height reductionTwo moderate vertebral fragility fractures or reduction in vertebral body height of 26–40% — imaging supporting fracture or height reduction must be submitted.

One severe fracture or >40% height reductionOne severe vertebral fragility fracture or reduction in vertebral body height >40% — imaging supporting fracture must be submitted.