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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHMSA Evenity Coverage Policy Update | OpenPayer
    Ask Trek AI about this page
    CurrentHawaii Medical Service Association (HMSA)Policy N/A

    Evenity (romosozumab-aqqg) coverage for postmenopausal osteoporosis

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    This policy governs HMSA prior authorization and coverage for Evenity in HMO, PPO, and QUEST members with postmenopausal osteoporosis. Coverage requires applicable clinical criteria, supporting documentation, and adherence to the 12-month dosing limitation.

    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyEvenity (romosozumab-aqqg) coverage for postmenopausal osteoporosis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateDec 19, 2025
    Last ReviewMay 1, 2025
    Next Review DateN/A
    Key ActionPrecertification is required for Evenity coverage; submit the HMSA medical specialty drug policy fax form.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 dosesMaximum Evenity treatment duration

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≥1 year
    Bisphosphonate trial when applicable
    ≤ -2.5Pre-treatment T-score threshold
    26–40%Moderate fracture height reduction
    >40%Severe fracture height reduction
    <35 mL/minCreatinine clearance threshold

    Coverage Criteria

    Initial therapy: postmenopausal osteoporosis

    Authorization of 12 months may be granted to postmenopausal members with osteoporosis when ANY of the following criteria are met.

    Qualifying postmenopausal osteoporosis pathway

    • DEXA criterion

      • DEXA score is -3.0, even in the absence of fracture.-3.0

    • Moderate vertebral fracture criterion

      • There are two moderate vertebral fragility fractures or a reduction in vertebral body height of 26–40%.26–40% reduction

    • Severe vertebral fracture criterion

      • There is one severe vertebral fragility fracture or a reduction in vertebral body height of more than 40%.>40% reduction

    • Multiple vertebral fracture criterion

      • There is a history of more than 2 vertebral fragility fractures.>2 fractures

    • Low T-score with fracture and bisphosphonate pathway

      • T-score and fracture

        • Pre-treatment T-score is less than or equal to -2.5.≤ -2.5
        • There is a history of any vertebral or radial fracture.

      • Bisphosphonate outcome

        • There is a documented inadequate response to an oral or injectable bisphosphonate trial of at least 1 year.≥1 year
        • There was an intolerable adverse event from an oral or injectable bisphosphonate.

    • Bisphosphonate and prior injectable therapy pathway

      • Bisphosphonate outcome

        • There is a documented inadequate response to an oral or injectable bisphosphonate trial of at least 1 year.≥1 year
        • There was an intolerable adverse event from an oral or injectable bisphosphonate.
        • There is a clinical reason to avoid treatment with an oral or injectable bisphosphonate.

          See the policy appendix for applicable clinical reasons.

      • Prior injectable osteoporosis therapy outcome

        • The member failed prior treatment with injectable osteoporosis therapy for which the member is eligible.

          Examples include denosumab (Prolia) and abaloparatide (Tymlos).

    Continuation therapy

    All members, including new members, requesting continuation authorization must meet ALL of the following requirements.

    Continuation requirements

    • The member meets all initial authorization criteria.

      See Initial therapy: postmenopausal osteoporosis.

    • The member has received fewer than 12 monthly doses of Evenity.<12 monthly doses

    Clinical Thresholds

    DEXA score
    Qualifying DEXA score-3.0
    Fracture requirementQualifies even in the absence of fracture
    Authorization periodAuthorization may be granted for 12 months when a qualifying criterion is met
    Pre-treatment T-score
    Qualifying pre-treatment T-scoreLess than or equal to -2.5
    Required fracture history in this pathwayAny vertebral or radial fracture
    Additional requirementDocumented inadequate response to a bisphosphonate trial of at least 1 year, intolerable adverse event, or clinical reason to avoid bisphosphonate therapy

    Authorization and Documentation Requirements

    Prior Authorization

    Precertification Required

    Precertification is required for Evenity (romosozumab-aqqg). Review the HMSA medical specialty drug policy resources before submitting the request.

    Step Therapy

    Bisphosphonate Trial or Avoidance Required

    Document either an inadequate response to an oral or injectable bisphosphonate trial of at least 1 year, an intolerable adverse event, or a clinical reason to avoid oral or injectable bisphosphonate therapy. Qualifying reasons to avoid therapy may include esophageal abnormalities, active upper gastrointestinal disease, gastrointestinal malabsorption, inability to remain upright or appropriately time oral dosing, creatinine clearance <35 mL/min, or prior intolerance to an oral bisphosphonate.

    • The qualifying trial, intolerance, or avoidance rationale must be supported in the member’s chart notes.
    • The requirement applies to the applicable postmenopausal osteoporosis pathway.

    Clinical Background

    Evenity (romosozumab-aqqg) is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture. This includes members with a history of osteoporotic fracture, multiple fracture risk factors, or failure or intolerance of other available osteoporosis therapy. Treatment is limited to 12 monthly doses; if additional osteoporosis therapy remains warranted, an anti-resorptive agent should be considered.

    Policy Definitions

    High risk for fracture
    Osteoporotic fracture historyHistory of osteoporotic fracture
    Multiple risk factorsMultiple risk factors for fracture
    Prior osteoporosis therapyFailure or intolerance to other available osteoporosis therapy
    Clinical reason to avoid bisphosphonate therapy
    Esophageal abnormalitiesAnatomic or functional abnormalities that might delay tablet transit, such as achalasia, stricture, or dysmotility
    Active upper gastrointestinal diseaseDysphagia, gastritis, duodenitis, erosive esophagitis, or ulcers
    Gastrointestinal malabsorption

    Initial Therapy for Postmenopausal Osteoporosis

    Initial therapy for postmenopausal osteoporosis

    Authorization of 12 months may be granted to postmenopausal members with osteoporosis when ANY qualifying criterion is met.

    Qualifying postmenopausal osteoporosis pathway

    • DEXA criterion

      • DEXA score is -3.0, even in the absence of fracture.-3.0

    • Moderate vertebral fracture criterion

      • There are two moderate vertebral fragility fractures or a reduction in vertebral body height of 26–40%.26–40% reduction

    • Severe vertebral fracture criterion

    Continuation of Evenity

    Continuation of Evenity

    All members, including new members, requesting continuation authorization must meet all initial authorization criteria and have received fewer than 12 monthly doses of Evenity.

    Continuation requirements

    • The member meets all initial authorization criteria.

      See Initial therapy for postmenopausal osteoporosis.

    • The member has received fewer than 12 monthly doses of Evenity.<12 monthly doses

    Step-Therapy Requirements

    StepRequirementDetails
    1Trial of an oral or injectable bisphosphonate, unless there is an applicable clinical reason to avoid treatment.The trial must last at least 1 year when trialed. A documented inadequate response or intolerable adverse event, or a clinical reason to avoid therapy, may satisfy this requirement.
    StepRequirementDetails
    2Previous injectable osteoporosis therapy, such as denosumab (Prolia) or abaloparatide (Tymlos), when the member is eligible for that therapy.The member must have failed prior treatment or be intolerant to the previous injectable osteoporosis therapy.

    Treatment Duration Limit

    Evenity (romosozumab-aqqg)
    Maximum treatment duration12 monthly doses
    DrugEvenity (romosozumab-aqqg)
    Continuation limitContinuation authorization requires fewer than 12 monthly doses; treatment beyond 12 monthly doses does not meet the stated requirement
    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyEvenity (romosozumab-aqqg) coverage for postmenopausal osteoporosis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateDec 19, 2025
    Last ReviewMay 1, 2025
    Next Review DateN/A
    Key ActionPrecertification is required for Evenity coverage; submit the HMSA medical specialty drug policy fax form.
    SourceLink
    On This Page
    Coverage CriteriaClinical ThresholdsAuthorization and Documentation RequirementsClinical BackgroundPolicy DefinitionsInitial Therapy for Postmenopausal OsteoporosisContinuation of EvenityStep-Therapy RequirementsTreatment Duration Limit
    There is a clinical reason to avoid treatment with an oral or injectable bisphosphonate.

    See the policy appendix for applicable clinical reasons.

  1. The member is intolerant to previous injectable osteoporosis therapy for which the member is eligible.

    Examples include denosumab (Prolia) and abaloparatide (Tymlos).

    2. Moderate vertebral fragility fracture or vertebral body height reduction
    Moderate fracture thresholdTwo moderate vertebral fragility fractures
    Vertebral body height reduction26–40% reduction in vertebral body height
    Authorization pathwayEither the fracture count or the vertebral body height reduction may satisfy this criterion
    Severe vertebral fragility fracture or vertebral body height reduction
    Severe fracture thresholdOne severe vertebral fragility fracture
    Vertebral body height reductionMore than 40% reduction in vertebral body height
    Authorization pathwayEither one severe fracture or the specified vertebral body height reduction may satisfy this criterion
    Bisphosphonate trial
    Required durationAt least 1 year
    Eligible therapyAn oral or injectable bisphosphonate
    Qualifying outcomeDocumented inadequate response; an intolerable adverse event or clinical reason to avoid therapy may substitute for a trial
    Creatinine clearance
    Creatinine clearance thresholdLess than 35 mL/min
    Clinical significanceListed as renal insufficiency and a clinical reason to avoid bisphosphonate therapy
    Therapy affectedOral and/or injectable bisphosphonate therapy
    Step Therapy

    Prior Injectable Therapy Requirement

    For the applicable pathway, document that the member has failed prior treatment with or is intolerant to a previous injectable osteoporosis therapy, such as denosumab (Prolia) or abaloparatide (Tymlos).

    Documentation Required

    Clinical Records Supporting Authorization

    Submit supporting chart notes or medical records needed to initiate review, including the member’s pre-treatment T-score; history of fragility, vertebral, or radial fractures; bisphosphonate trial, intolerance, or avoidance rationale; prior injectable osteoporosis treatment failure or intolerance; and documentation of vertebral fragility fracture or reduction in vertebral body height, as applicable.

    • Include the clinical documentation applicable to the requested authorization pathway.
    Prior Authorization

    Precertification Submission

    Submit the precertification request using the fax form available through the HMSA medical specialty drug policy website.

    • Direct providers to the HMSA medical specialty drug policy website for the required fax form.
    Denial Risk

    Failure to Meet Initial Criteria

    Initial authorization may be denied when the member does not satisfy at least one qualifying postmenopausal osteoporosis pathway. The applicable pathway must be supported by the required clinical records and documentation.

    • Qualifying pathways include the specified DEXA or fracture findings, or the required bisphosphonate and prior injectable therapy history where applicable.
    Denial Risk

    12-Dose Limit and Continuation Criteria

    Continuation requests must meet all initial authorization criteria and must be submitted before the member has received 12 monthly doses of Evenity. Continuation may be denied after the 12-dose limit or when the initial criteria are not met.

    • The continuation rule applies to all members, including new members requesting continuation of therapy.
    • Treatment beyond 12 monthly doses is not authorized under these criteria.

    Unsupported block type: billing_rule

    Documented or potential malabsorption, such as after gastric bypass or with celiac disease, Crohn's disease, or infiltrative disorders
    Positioning limitationInability to stand or sit upright for at least 30 to 60 minutes
    Administration limitationInability to take an oral bisphosphonate at least 30 to 60 minutes before the first food, drink, or medication of the day
    Renal insufficiencyCreatinine clearance less than 35 mL/min
    Prior intoleranceHistory of intolerance to an oral bisphosphonate
    • There is one severe vertebral fragility fracture or a reduction in vertebral body height of more than 40%.>40% reduction

  2. Multiple vertebral fracture criterion

    • There is a history of more than 2 vertebral fragility fractures.>2 fractures

  3. Low T-score with fracture and bisphosphonate pathway

    • T-score and fracture

      • Pre-treatment T-score is less than or equal to -2.5.≤ -2.5
      • There is a history of any vertebral or radial fracture.

    • Bisphosphonate outcome

      • There is a documented inadequate response to an oral or injectable bisphosphonate trial of at least 1 year.≥1 year
      • There was an intolerable adverse event from an oral or injectable bisphosphonate.
      • There is a clinical reason to avoid treatment with an oral or injectable bisphosphonate.

        See the policy appendix for applicable clinical reasons.

  4. Bisphosphonate and prior injectable therapy pathway

    • Bisphosphonate outcome

      • There is a documented inadequate response to an oral or injectable bisphosphonate trial of at least 1 year.≥1 year
      • There was an intolerable adverse event from an oral or injectable bisphosphonate.
      • There is a clinical reason to avoid treatment with an oral or injectable bisphosphonate.

        See the policy appendix for applicable clinical reasons.

    • Prior injectable osteoporosis therapy outcome

      • The member failed prior treatment with injectable osteoporosis therapy for which the member is eligible.

        Examples include denosumab (Prolia) and abaloparatide (Tymlos).

      • The member is intolerant to previous injectable osteoporosis therapy for which the member is eligible.

        Examples include denosumab (Prolia) and abaloparatide (Tymlos).