CurrentHighmark DelawarePolicy N/A

Outpatient Medical Injectable Prolia (denosumab) Authorization Request Form

Form and clinical questions used to request prior authorization for outpatient medical benefit administration of Prolia (denosumab) for Highmark Delaware members. Intended for providers/facilities submitting authorization requests (buy-and-bill or specialty pharmacy supplied).

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Medical Injectable Prolia (denosumab) Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Prolia authorization request form with clinical details and fax to Highmark at 1-833-619-5745 for medical benefit administrations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior Authorization Formdocument type

Denosumab (Prolia)drug addressed

Fax: 833-619-5745submission method

Policy Snapshot

This form is used to request prior authorization for outpatient medical benefit administration of Prolia (denosumab) for Highmark Delaware members. It is intended for providers and facilities submitting authorization requests — whether via Buy & Bill or supplied by a Specialty Pharmacy — and collects the administrative and billing details needed to process a medical benefit request, including member identifiers, payer type (Medicare or Commercial), requesting provider and facility information, date of service, and J-code(s)/diagnosis code(s).

Overview

Document typePrior Authorization Form

Drug addressedDenosumab (Prolia)

Submission methodFax: 833-619-5745

Information Required for Authorization

Information required for authorization

Authorization will require completion of the following clinical information; requests should include all pertinent attachments:

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Medical Injectable Prolia (denosumab) Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Prolia authorization request form with clinical details and fax to Highmark at 1-833-619-5745 for medical benefit administrations.

SourceLink

On This Page

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ALL of the following

Member identifiers and benefit verification (name, DOB, UMI); indication of Medicare or Commercial coverage
Requesting provider and facility information including NPI, contact phone/fax, date of service, J-code(s), and diagnosis code(s)
Specification of acquisition method: Buy & Bill OR Supplied by Specialty Pharmacy (include speciality pharmacy name and NPI if applicable)
Most recent DEXA T-scores and date of DEXA
History of trial and failure of at least one bisphosphonate OR documentation of contraindication to bisphosphonate therapy
Form asks: 'Has the member tried and failed at least one bisphosphonate? If so list which and why; duration of therapy; contraindications if any.'
History of osteoporotic fracture (yes/no). If yes, specify bone and date of fracture.
FRAX assessment (if used): 10-year risk of major osteoporotic fracture and 10-year risk of hip fracture
Sex-specific items (provide applicable)
- If female: confirm post-menopausal status and whether taking an adjuvant aromatase inhibitor for breast cancer (name of medication if applicable)
- If male: indicate if receiving androgen deprivation therapy for non-metastatic prostate cancer (name of medication if applicable)
Attach all pertinent clinical information (checkbox for attachment present)

What Providers Must Do

Prior Authorization

Complete and fax authorization form

Complete the Prolia authorization request form and fax the medical-benefit administration request to Highmark at 1-833-619-5745. This form is for outpatient medical benefit requests and collects required clinical and billing information for administration (include J-code(s) and diagnosis).

Affected code: J0897

Documentation Required

Document prior bisphosphonate use or contraindication

Document whether the member tried and failed at least one bisphosphonate or state that bisphosphonates are contraindicated; include the specific agent(s), duration of therapy, and reason for failure or the nature of the contraindication.

List bisphosphonate agent(s) used
Specify duration of therapy
State reason for treatment failure or detail the contraindication

Documentation Required

Attach supporting clinical records

Attach all pertinent clinical records to support medical necessity, as indicated on the form.

Most recent DEXA report with T-scores and date
Documentation of any osteoporotic fracture (bone and date)
FRAX calculation results (10-year major osteoporotic fracture and hip fracture risk)
Details of relevant cancer therapy (e.g., aromatase inhibitor name or androgen deprivation therapy medication)

Clinical and Administrative Context

The form is specific to outpatient medical benefit requests for Prolia (denosumab) and collects the clinical information typically required to demonstrate medical necessity for fracture risk reduction. Required clinical items include the most recent DEXA T-score and date, documentation of trial and failure of at least one bisphosphonate (including which agent, duration, and reason for failure) or documented contraindication to bisphosphonate therapy, and history of osteoporotic fracture with bone and date if applicable.

Additional clinical data requested are the use of a FRAX assessment (provide the 10-year risk of major osteoporotic fracture and the 10-year risk of hip fracture), and cancer-therapy–related items: for females, post-menopausal status and whether the member is taking an adjuvant aromatase inhibitor (include medication name); for males, whether the member is receiving androgen deprivation therapy for non-metastatic prostate cancer (include medication name). The form also instructs providers to attach all pertinent clinical records and to fax the completed form to Highmark at 1-833-619-5745.

J0897	Denosumab (Prolia) — typical J-code to be entered on form (form has a J Code(s) field)
ICD-10	Diagnosis code(s) — free text field for relevant ICD-10 codes (e.g., osteoporosis codes not specified on form)

OpenPayer

Outpatient Medical Injectable Prolia (denosumab) Authorization Request Form

Policy Snapshot

Information Required for Authorization

Codes and Form Fields

What Providers Must Do

Clinical and Administrative Context

Defined Terms on the Form