CurrentUnitedHealthcarePolicy CSOH2026D0080.C

Evenity (romosozumab-aqqg) — Ohio medical benefit drug policy

This policy governs medical benefit coverage of Evenity (romosozumab-aqqg) for members of UnitedHealthcare Community Plan in the state of Ohio and directs providers to Ohio Medicaid clinical criteria for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyEvenity (romosozumab-aqqg) — Ohio medical benefit drug policy

Policy CodePolicy CSOH2026D0080.C

Change TypeRevised coverage rationalesupporting sections removed

Effective DateApr 1, 2026

Next Review Date

Key ActionFollow the Ohio Department of Medicaid Unified Preferred Drug List Criteria for prior authorization and clinical coverage decisions.

SourceLink

POLICY UPDATE CHANGES

Replaced coverage guidelines with language indicating Evenity is considered medically necessary in certain circumstances and directs readers to the Ohio Department of Medicaid Unified Preferred Drug List Criteria for clinical coverage criteria.

Ohio-onlygeographic scope

Ohio Medicaid UPDLclinical criteria source

Applicable Codes & evidencesections removed

Coverage Criteria — Evenity (romosozumab-aqqg)

Policy Summary

PayerUnitedHealthcare

PolicyEvenity (romosozumab-aqqg) — Ohio medical benefit drug policy

Policy CodePolicy CSOH2026D0080.C

Change TypeRevised coverage rationalesupporting sections removed

Effective DateApr 1, 2026

Next Review Date

Key ActionFollow the Ohio Department of Medicaid Unified Preferred Drug List Criteria for prior authorization and clinical coverage decisions.

SourceLink

On This Page

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This policy was revised effective 04/01/2026. The update replaced the former detailed coverage guidelines with a concise coverage rationale stating that Evenity (romosozumab-aqqg) is considered medically necessary in certain circumstances and directs readers to the Ohio Department of Medicaid Unified Preferred Drug List (UPDL) Criteria for clinical coverage rules. Several supporting sections were removed from this document, specifically: Applicable Codes, Background, Clinical Evidence, FDA, and References. The prior policy version CSOH2025D0080.B has been archived.

Initial Therapy — Ohio Medicaid UPDL Determinations

Initial therapy per Ohio Medicaid UPDL

Initial coverage decisions are determined by the Ohio Department of Medicaid Unified Preferred Drug List Criteria.

Initial therapy governed externally: Specific initial therapy eligibility requirements are those listed in the Ohio Department of Medicaid Unified Preferred Drug List Criteria.see Ohio Medicaid UPDL

Policy delegates clinical criteria to Ohio Medicaid UPDL

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Ohio Medicaid prior authorization criteria apply. Requests for coverage will be evaluated according to Ohio Department of Medicaid requirements (including the Ohio Administrative Code 5160-1-01 and the Ohio Department of Medicaid Unified Preferred Drug List criteria) when those requirements govern benefit coverage.

Prior authorization governed by Ohio Medicaid criteria and the Ohio Department of Medicaid Unified Preferred Drug List (UPDL).

Denial Risk

Denial Risk for Non‑Concordant Requests

Requests that do not follow Ohio Medicaid governing criteria or the applicable federal/state/contractual requirements may be denied. Submit complete, concordant documentation to reduce denial risk.

Non‑concordant prior authorization requests are subject to denial under Ohio Medicaid rules.

Documentation Required

Documentation and Governing Rules

When requesting coverage, providers must supply documentation that meets federal, state (OAC), and any contractual requirements. Include clinical records, prior therapy history, relevant diagnostic information, and any documentation specified by the Ohio Department of Medicaid UPDL. UnitedHealthcare may also use third‑party clinical tools (e.g., InterQual®) in adjudication.

Provide clinical records and prior therapy history as required by Ohio Medicaid and the UPDL.
Include any documentation specifically requested on the prior authorization form or by UnitedHealthcare/Ohio Medicaid.

Step Therapy

Step Therapy Not Included — See Ohio Medicaid UPDL

Step therapy specifics are not included in this policy. For step therapy requirements and sequencing, refer to the Ohio Department of Medicaid Unified Preferred Drug List (UPDL) and applicable state guidance.

Step therapy requirements governed by Ohio Medicaid UPDL — check UPDL for required prior agents, step edits, and exceptions.

OpenPayer

Evenity (romosozumab-aqqg) — Ohio medical benefit drug policy

Coverage Criteria — Evenity (romosozumab-aqqg)

Initial Therapy — Ohio Medicaid UPDL Determinations

Provider Actions, Prior Authorization, and Documentation

Definitions and Scope

Step Therapy Requirements