Denosumab (Prolia & Xgeva) and Associated Biosimilars

Covers denosumab (Prolia®, Xgeva®) and listed biosimilars for treatment and continuation in indications such as postmenopausal osteoporosis, osteoporosis in men, glucocorticoid‑induced osteoporosis, patients on aromatase inhibitors or androgen‑deprivation therapy, giant cell tumor of bone, prevention of skeletal‑related events in bone metastases or multiple myeloma, and hypercalcemia of malignancy. Coverage requires proven effectiveness with dosing/frequency/duration per authoritative sources (e.g., FDA labeling), meeting specific criteria (T‑score/FRAX thresholds), prior ≥1‑year oral or injectable bisphosphonate trial or a documented clinical reason to avoid bisphosphonates (or recent IV bisphosphonate refractoriness for cancer indications), continuation only if benefit is demonstrated, and off‑label uses must be supported by two peer‑reviewed articles; coverage is subject to the member’s contract and state regulations.

"Therapies must be proven effective for the relevant diagnosis or procedure to be covered."