Evenity (romosozumab) — Outpatient Injectable Authorization Criteria
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Authorization form and clinical questionnaire for outpatient administration of Evenity (romosozumab) under the medical benefit; intended for providers requesting prior authorization for Highmark BlueShield members in the applicable service region.
No material clinical or coverage changes in this revision.
Coverage & Authorization Criteria
Submission requirements for authorization
Authorization assessment requires submission of ALL requested clinical items; approval is contingent on review of the documentation provided.
Form explicitly requests these items to evaluate authorization
The authorization form explicitly asks whether Evenity will be given concurrently with other anabolic or antiresorptive agents. Specifically, providers must indicate if the member will receive Evenity in combination with parathyroid hormone analogs (for example, Forteo or Tymlos) and/or RANKL inhibitors (for example, Prolia or Xgeva). This information is collected to inform the clinical review; the form queries concomitant use rather than describing separate coverage rules for combination therapy.
The document does not list specific scenarios that are categorically not medically necessary. However, the form emphasizes tracking cumulative lifetime exposure: providers must state whether the member still needs to complete twelve (12) doses per lifetime, report how many doses are being requested, and provide the number and date of any prior Evenity injections. Completion of the 12-dose lifetime allowance is a required element of the authorization submission and will be used during review.
Billing and Coding
| HCPCS | Drug Name and HCPCS Code (provider to supply specific code) |
| ICD-10 | ICD10 Diagnosis Code(s) (provider to supply specific code(s)) |
Provider Submission & Documentation Actions
Prior authorization required — use form and fax
Submit a prior authorization using the Outpatient Medical Injectable EVENITY Authorization Request Form and fax it to 833-581-1861. Include the Drug Name and the HCPCS code on the form and indicate the number of doses being requested and how many prior Evenity doses the member has received.
- Fax number: 833-581-1861
- Include Drug Name and HCPCS Code on the form
- State number of doses requested and number of prior Evenity doses received
Document prior bisphosphonate trial (agent, duration, reason)
Document that the member has tried and failed at least one bisphosphonate, specifying which agent(s), duration of therapy, and the reason for failure or contraindication.
- List which bisphosphonate(s) were used
- Provide duration of each bisphosphonate trial
- State reason for failure or any contraindication to bisphosphonate therapy
Attach required documentation and verify benefits
Attach a completed authorization form with member demographics, ordering/provider and facility NPIs, the Drug Name and HCPCS code, ICD-10 diagnosis code(s), recent DEXA T-scores with the DEXA date, bisphosphonate trial details (including duration and reason or contraindication), fracture history with dates, FRAX results if used, concomitant osteoporosis therapies, number of prior Evenity doses and number of doses requested, and supporting clinical records. Verify member eligibility and benefits.
- Member name, date of birth, member ID
- Ordering/attending provider name and NPI; facility/vendor name and facility NPI
- Drug Name and HCPCS Code; ICD-10 diagnosis code(s)
- Recent DEXA T-score(s) with date of scan
- Bisphosphonate trial details: agents, duration, reason for failure or contraindication
- Fracture history (site and date) and FRAX scores if used
- Number of prior Evenity doses, date of last injection, and number of doses requested
- Attach all pertinent clinical information and verify eligibility/benefits
Risk of denial or delay if clinical documentation is incomplete
Failure to provide requested clinical information — such as recent DEXA with T-scores and date, details of bisphosphonate trials (agents, duration, reason for failure or contraindication), fracture history, FRAX results, prior Evenity dose history, and attachments — may delay or result in denial of the authorization.
- Missing DEXA T-scores and scan date
- Missing bisphosphonate trial duration or reason for failure/contraindication
- Absent fracture site/date or FRAX results
- No documentation of prior Evenity doses or missing clinical attachments
Background
Evenity (romosozumab) is an injectable anti-osteoporosis agent. The authorization form requests objective clinical data commonly used to evaluate appropriateness for Evenity, including recent DEXA T-scores with dates, fracture history, prior osteoporosis therapy (e.g., bisphosphonate) trial details, FRAX results if used, and documentation of prior Evenity dosing. These items support the typical rationale for authorization: demonstration of osteoporosis severity, prior treatment attempts or contraindications, fracture risk assessment, and confirmation of remaining lifetime doses.
Definitions & Clinical Tools
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