CurrentHighmark DelawarePolicy N/A

Outpatient authorization form and coverage criteria for EVENITY (romosozumab)

Authorization request form and required clinical information for outpatient medical benefit coverage of EVENITY (HCPCS J3111) for Highmark Delaware members; used by ordering providers and facilities to request approval and document medical necessity.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient authorization form and coverage criteria for EVENITY (romosozumab)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed authorization form via fax to 833-581-1861 with required clinical documentation including DXA T-score, prior bisphosphonate history, fracture history, and number of prior EVENITY doses.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

J3111HCPCS code for EVENITY

12Max injections (lifetime)

833-581-1861Fax to submit form

T-scoreDXA required

Coverage Criteria for EVENITY (romosozumab)

Policy Summary

PayerHighmark Delaware

PolicyOutpatient authorization form and coverage criteria for EVENITY (romosozumab)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Authorization criteria (form completion and supporting documentation)

Covered when ALL of the following are documented on the authorization form:

All required information: Provider submits a completed authorization form including member identification, HCPCS J3111 (EVENITY), ICD-10 diagnosis code(s), and requested start date; faxed to 833-581-1861; includes most recent DEXA T-score and date; documents prior bisphosphonate use (agent, duration, reason for failure) or states contraindication; documents history of osteoporotic fracture (site and date) and FRAX results if used; indicates whether member is post-menopausal; states number of doses requested, number of prior EVENITY doses received, and date of last injection; and attaches pertinent clinical records.

Form also asks whether EVENITY will be given in combination with parathyroid hormone analogs or RANKL inhibitors; attach supporting documentation as applicable.

Dosing limits

Coverage limited by lifetime dosing constraint:

Lifetime dose limit: Evenity (romosozumab) is limited to twelve (12) injections per lifetime; authorization must document whether the member still needs to complete twelve doses, how many doses are being requested, number of prior doses received, and date of last injection.<= 12 total injections per lifetime

Form includes checkboxes and fields to confirm remaining doses and requests attachment of prior dosing information.

The form does not state separate coverage for requests lacking required information. If the provider fails to supply the requested clinical documentation—such as recent DEXA T-score and date, prior bisphosphonate trial details (drug, duration, reason for failure or contraindication), fracture history, FRAX results if used, number of prior Evenity doses, or other pertinent attachments—the request may be denied. Additionally, authorization requests that exceed the payer's lifetime limit for Evenity will not be approved; the form asks whether the member still needs to complete twelve (12) doses per lifetime and requires the number of prior and requested doses to document remaining allowable doses.

Coding and Dose Limits

Requested drug HCPCSHCPCS

J3111

EVENITY

inv-06: Evenity lifetime dose limit

Lifetime dosing limitEvenity is limited to twelve (12) injections per lifetime.

Authorization must document prior dosesAuthorization must state how many previous doses the member has received and date of last Evenity injection.

Requester must indicate remaining dosesForm asks whether the member still needs to complete twelve (12) doses per lifetime and how many doses are being requested.

Attach clinical recordsAuthorization requires attachment of pertinent clinical information to support dosing history and need for additional doses.

Provider Actions and Submission Requirements

Prior Authorization

Prior authorization required for EVENITY (J3111)

Prior authorization is required for EVENITY (HCPCS J3111). Submit the completed Evenity authorization form with supporting clinical information to Highmark Delaware for review prior to outpatient administration.

Step Therapy

Prior bisphosphonate trial queried on form

The authorization form asks whether the member has tried and failed at least one bisphosphonate and requests the name of the bisphosphonate, reason for failure, duration of therapy, and any contraindications.

List which bisphosphonate was tried and why it failed
Provide how long the member took the bisphosphonate(s)
Document any contraindications to bisphosphonate therapy

Documentation Required

Required documentation and fax submission

Submit the completed authorization form via fax to 833-581-1861 with member demographics, HCPCS J3111, ICD-10 diagnosis code(s), requested start date, DEXA T-score(s) with date, prior bisphosphonate trial details, fracture history, FRAX results if used, number of prior EVENITY doses, and pertinent attachments.

Include member name, DOB, Member ID and provider/facility information
Provide DEXA T-scores and date of scan
State number of doses requested and previous Evenity doses; date of last injection
Attach pertinent clinical records

Denial Risk

Incomplete documentation may lead to denial or delay

Failure to provide requested clinical documentation or to complete and fax the authorization form (including DEXA T-score/date, prior bisphosphonate details, fracture history, FRAX score, number of prior doses, and attachments) may result in denial or delay of coverage.

Missing DEXA T-score or date
Absent details of prior bisphosphonate therapy (drug, duration, reason for failure/contraindication)
No fracture history or FRAX results when applicable
Failure to attach pertinent clinical information or to fax the form

Definitions

inv-12: Evenity lifetime dose limit — Lifetime dosing limit: Evenity is limited to twelve (12) injections per lifetime.

Lifetime dosing limit (policy text)Lifetime dosing limit: Evenity is limited to twelve (12) injections per lifetime.

Form prompts for dose completion statusForm asks whether the member still needs to complete twelve (12) doses per lifetime (Yes/No).

Required dose counts on formForm requests how many doses of Evenity are being requested and how many previous doses the member has received, plus date of last injection.

Documentation requirementPlease attach all pertinent clinical information when submitting the authorization form.

OpenPayer

Outpatient authorization form and coverage criteria for EVENITY (romosozumab)

Coverage Criteria for EVENITY (romosozumab)

Coding and Dose Limits

Provider Actions and Submission Requirements

Background

Definitions